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SAN,JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Food demonstrations/samples (2 00SL':E;t1 4 <br /> OWNER/OPERATOR <br /> Club Demonstration Services Inc. CHECK if BILLING ADDRESS❑ <br /> FACILITY NAME Club Demonstration Services Inc. <br /> SITE ADDRESS 1616 E Hammer Ln Stockton 95210 <br /> Street Number Direction I Street Name city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 15310 Barranca Parkway-Suite 100 <br /> Street Number Street Name <br /> CITY Irvine STATE CA ZIP 92618 <br /> PHONE#1 ExT' APN# N/A LAND USE APPLICATION# NIA <br /> ( 940) 295 7135 <br /> PHONE#2N/A ExT• BOS DISTRICT N/A LOCATION CODE <br /> ( ) N/A <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR Club Demonstration Services Inc. CHECK if BILLING ADDRESS <br /> BUSINESS NAME Club Demonstration Services Inc. PHONE# ExT' <br /> 940 295 7135 <br /> HOME or MAILING ADDRESS 15310 Barranca Parkway-Suite 100 FAx# N/A <br /> CITY Irvine STATE CA ZIP 92618 <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project <br /> or activity will be billed to me or my business as identified on this form. <br /> 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 <br /> COUNTY Ordinance Codes,Standards,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: 8/ hall Rely COW tallCe C00dillat0t- DATE: 11/17/2021 <br /> - <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORiZEDAGENT Compliance Coordinator <br /> If APPLICANT is not the BILLING PAR Tr proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable,I, the owner or operator of the property located at the <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmentaUsite assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: RECEIVE <br /> COMMENTS: NOV 2 2 2W <br /> Club demonstrations services at Costco. r L (� (��( <br /> sax JOAQUIN COUtm• <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: Vidal Pedraza EMPLOYEE#: 6213 DATE: 11_19-21 <br /> ASSIGNEDTO: Daria AFOnskaia EMPLOYEE#: 982.5 DATE: 11-19-21 <br /> Date Service Completed (if already completed): SERVICE CODE: 061 PIE: 1602 <br /> Fee Amount: 152 Amount Paid i S'L Payment Date IL U y( <br /> Payment Type `1 Invoice# Check# / q / Received By: <br /> EHD 48-02-025 Payment confirmation# 134929090 Ll/ l / �/� SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />