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SAN JOAQUIN COUNTY Ii.NVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />-T <br />CHECK If BILLING ADDRESS <br />FACILITY ID # <br />11 <br />SERVICE REQUEST # <br />Yoga studio <br />ACCEPTED BY: ��� <br />-2- 2- lJ- t <br />CITY <br />$K(LV.+I'kiLi "l C� <br />OWNER / OPERATOR <br />EMPLOYEE#: <br />DATE: 2 _ t 5 -22 <br />Date Service Completed (If already completed): <br />CHECK If BILLING ADDRESS <br />SERVICE CODE: <br />Lisa Beaty <br />PIE' nZ <br />FACILITY NAME <br />Amount Paid <br />MINDBEATY&SOUL LLC dba True You Hot Yoga <br />SITE ADDRESS 2341Pacific <br />Invoice # <br />Check # <br />Ave <br />Stockton <br />95204 <br />Street Number <br />Direction <br />Street Name <br />City <br />Zip Coe. <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />12 <br />E. Atlee St. <br />Street Number <br />Street Name <br />CITY <br />STATE Ca ZIP 95204 <br />Stockton <br />PHONE #1 EXT. <br />APN # <br />LAND USE APPLICATION # <br />( ) 209588-6892 <br />PHONE #2 EAT• <br />( ) <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR Lisa Beaty <br />CHECK If BILLING ADDRESS <br />BUSINESS NAME <br />MINDBEATY&SOUL LLC dba True You Hot Yoga <br />COMMENTS: <br />PHONE# EXT. <br />209-688.6892 <br />HOME or MAILING ADDRESS 12 E. Atlee St Stockton Ca 95204 <br />ACCEPTED BY: ��� <br />FAX# <br />RAYJ <br />CITY <br />STATE ZIP REc <br />' <br />ENT <br />BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agen sa1me,VED <br />acknowledge that all site and/or project Specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges aSSOClated tVith l Oj 6 <br />or activi will b billed t b• 'd t f- d th' F- <br />2023 <br />ty e e o me or my usmess as I an t to on is orm. SAN JOAQUIN COUNry <br />I also certify that I have prepared this application and that the work to be performed will be done in accordance with allAIp1ENTAl, <br />COUNTY Ordinance Codes, Standards, STATE and FEDERAL laws. TH DEPARTMENT <br />APPLICANT'S SIGNATURE: <br />DATE: <br />PROPERTY/ BUSINESS OWNER® OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT 13 <br />If APPLICANT is not the BILLING PARTY proof of authorization to sign is required Title <br />114/23 <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 the or my representative. <br />TYPE OF SERVICE REQUESTED: C. <br />COMMENTS: <br />ACCEPTED BY: ��� <br />EMPLOYEE #: q 1 O <br />` 1 <br />DATE: _ ` _ 2 <br />ASSIGNED TO: Le <br />EMPLOYEE#: <br />DATE: 2 _ t 5 -22 <br />Date Service Completed (If already completed): <br />SERVICE CODE: <br />PIE' nZ <br />Fee Amount: b -- <br />Amount Paid <br />Payment Date <br />Payment Type \ <br />Invoice # <br />Check # <br />Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 \ 2 <br />