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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # SERVICE REQUEST # <br /> Coffee Shop ` '(ZCDmB�+ LA Zc4 <br /> OWNER / OPERATOR <br /> CHECK If BILLING ADDRESS <br /> Laurie Dunn <br /> FACILITY NAME <br /> Brew House Coffee <br /> SITE ADDRESS 853 N CI uff Ave Lodi 95240 <br /> Street Number Direction Street Name City Zip Code <br /> HOME or MAILING ADDRESS ( If Different from Site Address ) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE # 1 ExT . APN # LAND USE APPLICATION # <br /> ( 916 ) 203 - 0847 <br /> PHONE #2 ExT . BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> Laurie Dunn CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE # ExT . + <br /> Brew House , LLC <br /> HOME or MAILING ADDRESS FAX # <br /> 115 S . School Street ( ) <br /> CITY Lodi STATE CA ZIP 92540 <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, Standa ds, STAT EDERAL laws . <br /> APPLICANT ' S SIGNA RE : DATE . 11 / 14/203 <br /> PROPERTY / BUSINESS OWNER ® OPERATOR MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> IfAPPLICANT 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 environmental/site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at thee_ time it is <br /> provided to me or my representative . <br /> elk <br /> TYPE OF SERVICE REQUESTED : <br /> COMMENTS : /yaV <br /> SAN CoA 142023 <br /> HFA TNRQO/NMFCOON <br /> DEpq � ryr <br /> NT <br /> ACCEPTED BY : o EMPLOYEE # : DATE : NOW <br /> SC <br /> J / <br /> ASSIGNED TO : ` s?. EMPLOYEE # : DATE : j f <br /> Date Service Completed ( if already completed ) : SERVICE CODE : PIE :/ <br /> Fee Amount : Amount Paid 1T• Payment Date 1 *3 <br /> Payment Type Invoice # Check # 17 f j Received By : 1771 <br /> EHD 48 -02 -025 SR FORM ( Golden Rod ) <br /> REVISED 11 / 17/2003 <br />