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s <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Food demonstrations/samples <br /> OWNER/OPERATOR <br /> Club Demonstration Services Inc. CHECK If BILLING ADDRESS <br /> FACIcmNAME Club Demonstration Services Inc. <br /> SITE ADDRESS 2680 Reynolds Ranch Pkwy Lodi 95240 <br /> StreetNumher I Direction I Street Name city Zip Code <br /> HOME or MAILING ADDRESS of Different from Site Address) 15310 Barranca Parkway-Suite 100 <br /> Street Number Stro.tName <br /> Cm'lrvine STATE CA LP 92618 <br /> PHONE#1 E%L APN# N/A N/A USE APPLICATION It NIA <br /> ( 940) 2957135 <br /> PHONE#2 N/A - En. 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 NAMECIUb Demonstration Services Inc. PHONE# E%. <br /> 940 1 295 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 ENvrRONMENTAL 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 /> I. <br /> APPLICANT'S SIGNATURE: 8t-ittall� RecJ DWtiMe COOdi%at0l- DATE: 11/17/2021 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENTIf Compliance Coordinator <br /> IfAPPLICANTisnotthe BILLWGPARTP proof of authorization to sign is required TWe <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 environmental/site assestsment <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 /> TYPEAF SERVICE REQUESTED: P/aYMENT <br /> COMMENTS: <br /> Club demonstrations services at Costco. NOV 2 2 2021 <br /> t Sa ENNA NIMENrAMT <br /> . NEpl1N DEPARiMEe <br /> j <br /> ACCEPTED BY: Vidal Pedraza EMPLOYEE#: 6213 DATE: 11_10_21 <br /> ASSIGNED TO: Daria Afonskala EMPLOYEE#: 9825 DATE: 11-19-21 <br /> Datd.Service Completed (if already completed): SERVICE CODE: 061 PIE: 1602 <br /> Fee Amount: 152 Amount Paid l S y Payment Date LJ( 2 �r <br /> Payment Type 5 Invoice# Check# I / Received By: <br /> EHDr48-02.025 Payment confirmation# 134928653 U,1 t pt <br /> / 4Z__ I SR FORM(Golden Rod) <br /> REVISED 11/17/2003 LLL _ 111 <br />