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�Q O O,-.uSign Envelope ID:OBE2BFE1-3308-4934B667-56C7DFAD61 E7 r)AN JOA(tulN I,UUN I Y ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID# SERVICE REEQUEST# Cupcake Bakery p(�22.33b OWNER/OPERATOR AC Brisco Corp/Smallcakes Lathrop CHECK if BILLING ADDRESS FACILITY NAME Smallcakes Lathrop SITE ADDRESS S Harlan Rd Lathrop 95330 15040 Street Number I Direction Street Name City Zip Code HOME or MAILING ADDRESS (If Different from Site Address) Mumbert Dr 2324 Street Number Street Name CITY STATE ZIP Manteca CA 95337 PHONE#1 En. APN# LAND USE APPLICATION (408 ) 221-0231 PHONE#2 Exr. BOS DISTRICT LOCATION CODE ( 1 CONTRACTOR/ SERVICE REQUESTOR REQUESTOR Ambrose Brism CHECK If BILLING ADDRESS BUSINESS NAME PHONE# Exr' Smallcakes Lathrop 408 221-0231 HOME Or MAILING ADDRESS FAX# 2324 Mumbert or ( ) Clry M.m.. 5CATE ZIP 95337 BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as identified on this form. I also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes,Standards S Td FEDERAL laws. APPLICANT'S SIGNATURE: b4rn,&ipsw DATE: 6/7/2021 PROPERTY/BUSINESS OWNER[aPER"ATOR/Me4YAGER 11OTHER AUTHORIZED AGENT❑ IfAPPL/CANT is not the BILLLNG PARTY proof of authorization to sign is required Title AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. P TYPE OF SERVICE REQUESTED: COMMENTS: ji)v 0 O SANS ,?O q �TH�Q M /hgTO ?1 y R MF ACCEPTED BY: EMPLOYEE#: 2 DATE: '-I /� ASSIGNED TO: , EMPLOYEE#: (' DATE: / Date Service Completed (if already completed): SERVICE923 pit: O .1 1 Fee Amount: Amount Paid t L) 90 90 Payment Date Payment Type C. le44L Invoiceq,# Check# I rr (-SZ Received By: REVISED 1117/20030 v V VCl 2�� SR FORM(Golden Rad)