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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />SERVICE RE/�QUEST # <br />Food demonstrations/samples <br />Club demonstrations services at Costco. <br /># <br />940 <br />cn <br />5G oo9,4 Sl (0 <br />OWNER I OPERATOR <br />EMPLOYEE#: 6213 <br />Club Demonstration Services Inc. <br />eNECK if BILLING ADDREss❑ <br />FACILTYNAME Club Demonstration Services Inc. <br />STATE CA <br />SITE ADDRESS 3250 <br />Date Service Completed (if already completed): <br />W Grant Line Rd <br />SERVICE CODE: 061 <br />Tracy <br />95304 <br />Street Number <br />Direction <br />Street Name <br />S' <br />city <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) 15310 <br />Barranca Parkway- Suite 100 <br />Street Number <br />Received By: <br />Street Name <br />CITY Irvine <br />STATE CA ZIP 92618 <br />PHONE#1 En. <br />APN # <br />LAND USE APPLICATION # <br />( 940) 295 7135 <br />N/A <br />N/A <br />PHONE#2 N/A Ear. <br />BOS DISTRICT N/A <br />LOCATION CODE <br />( 1 <br />N/A <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />Club Demonstration Services Inc. <br />CHECK if BILLING ADDRESS Rr <br />BUSINESS NAMEPHONE <br />Club Demonstration Services Inc. <br />Club demonstrations services at Costco. <br /># <br />940 <br />Ez . <br />295 7135 <br />HOME or MAILING ADDRESS 15310 Barranca Parkway- Suite 100 <br />EMPLOYEE#: 6213 <br />(Ax# ) <br />N/A <br />CITY Irvine <br />STATE CA <br />ZIP 92618 <br />BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or a* sized agent of same, <br />acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly chat- ..ociated 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 dor . to accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, STATE and FEDERAL laws. <br />APPLICANT'S SIGNATURE: 51-Itta;ly &Vek, rCIV(�'JGIG{ylGe 090i/I1at0Y DATE: 11/17/2021 <br />b <br />PROPERTY /BUSINEss OWNER❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENTVf Compliance Coordinator <br />g'APPLICANT is not the BILLPVG PAR proof of authorizafion to sign is required Tizte <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 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: <br />RECEIVED <br />COMMENTS: <br />Club demonstrations services at Costco. <br />NOV 2 2 2021 <br />��rL� <br />aANJOAOVINCOUNrY <br />ENVIRONMENTAL <br />HEALTHOp%wa tlT <br />ACCEPTED BY: <br />Vidal Pedraza <br />EMPLOYEE#: 6213 <br />DATE: 11_19-21 <br />ASSIGNED TO: <br />Kadeanne Linhares <br />EMPLOYEE#: 4559 <br />DATE: 11-19-21 <br />Date Service Completed (if already completed): <br />SERVICE CODE: 061 <br />PIE: 602 <br />Fee Amount: <br />152 <br />Amount Paid <br />S' <br />Payment Date <br />I( L 20 2( <br />Payment Type <br />Invoice # <br />Check # <br />Received By: <br />EHD 48-02-025 Payment confirmation # 134929350 Ll �/ q �?y 2 If <br />REVISED 11/17/2003 6 <br />SR FORM (Golden Rod) <br />