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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property FACILITY ID #SERVICE r, REQUEST # <br />R 00 .85 .02A10 <br />OWNER! OPERATOR <br />Katie Hausauer CHECK if BILLING ADDRESS <br />FACILITY NAME Squeeze Burger <br />SITE ADDRESS 100 <br />Street Number <br />S <br />Direction <br />Sacramento Street <br />Street Name <br />Lodi <br />City <br />95240 <br />Zip Code <br />HOME Of MAILING ADDRESS (If Different from Site Address) <br />Street Number Street Name <br />CITY STATE ZIP <br />PHONE #1 EXT. <br />( ) 209.327.6833 <br />APN # <br />043-04-04 <br />LAND USE APPLICATION # <br />PHONE #2 Exr. <br />( ) <br />BOS DiSTRICT <br />LOCII <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />John Vien-a CHECK If BILLING ADDRESS <br />BUSINESS NAME N jA Architecture PHONE # <br />) <br />EXT. <br />( 209.610.6036 <br />HOME or MAILING ADDRESS 212 W Pine Street Suite 1 <br />FAX # <br />( ) <br />CITY Lodi STATE CA ZIP 95240 <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: <br />PROPERTY / BUSINESS OWNER': OPERATOR / MANAGER 0 OTHER AUTHORIZED AGENT 0 <br />If APPLICANT is not the BILLING PARTY, 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 environmentakite assessment <br />information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at tiM4AirMt4rile it is <br />provided to me or my representative. <br />TYPE OF SERVICE REQUESTED: ( .C1X13-ti \.,k) <br />'''".1 V <br />AUG <br />COMMENTS: 0 5 20228 <br />SAN joA , <br />HE6WV/RIAIIN COUN I 4LTH DEpMENTAL 71 AP?TiviNT <br />ACCEPTED BY: -r,....4._ e 5 c_7, EMPLOYEE #: DATE: 9-•-• .- %IL <br />ASSIGNED TO: R \ OA, l -C., 2 EMPLOYEE #: DATE: r.,,---- - 3 --2-L <br />Date Service Qompleted (if already completed): SERVICE CODE: PIE: PIE: /6/0 / <br />Fee Amount: <br />g <br />Amount Pa1/O-L/68, 60 Payment Date 7//2,2___ <br />Payment Type ,eryri- Invoice # Check # l "-E7 4,-/-s- 3-62_ Receiv d By: <br />DATE: <br />Architect <br />1 1-7o 3‘„2— SR FORM (Golden Rod) EHD 48-02-025 <br />REVISED 11/17/2003