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i;v0s3 71S <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />Coffee Shop <br />FACILITY ID # <br />1 i cr 3 3 <br />SERVICE REQUEST # <br />SMB-iiCirb <br />OWNER! OPERATOR Starbucks CHECK if BILLING ADDRESS <br />FACILITY NAME Starbucks Hwy 99 and Harney <br />SITE ADDRESS 2620 <br />Street Number Direction <br />Reynolds Ranch Pkwy <br />Street Name <br />Lodi <br />City <br />95240 <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Street Number Street Name <br />Crrv STATE ZIP <br />PHONE #1 Exr. <br />( ) <br />APN # <br />058-650-07 <br />LAND USE APPLICATION # <br />PHONE #2 Exr. <br />( ) <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR Maria Benasa CHECK if BILLING ADDRESS <br />BUSINESS NAME Valerio Architects PHONE # <br />( <br />, <br />I <br />323.954.8996 <br />EXT. <br />HOME or MAILING ADDRESS 5858 Wilshire Blvd. #200 FAX # <br />( ) <br />CITY Los Angeles STATE CA ZIP 90036 <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 HEALTII 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 />AR („bi,/,54 <br />PROPERTY / BUSINESS OWNER 0 OPERATOR / AANAGER 0 <br />€7/S1#3 <br />OTTER AUTHORIZED AC ENT J2r er 2157I-Cf CAC-WI-01i \-41-Int_ <br />APPLICANT'S SIGNATURE: DATE: <br />if A ppLicANT is not the BILLING PARTY. proof of authorization to sign is required <br />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 ENVIRONMENTAI HEALTH DI PARTMENT as soon as it is available and time it is <br />provided to me or my representative. <br />TYPE OF SERVICE REQUESTED:1 <br />, <br />Fie ki4, D.-le <br />i <br />- ‘..C/ v-t3 <br />Sep I Jr COMMENTS: 1 2023 <br />SAN Jo , <br />t..1 t\IVI13,1QUIN Cr, ''SALTH ,(DNMEN—,UNTy <br />4-)EPA R ,./AL <br />i MENT <br />ACCEPTED BY: c A r ‘ra esc 0 EMPLOYEE #: DATE: 9 _ i s- _ 23 <br />ASSIGNED TO: RA vet z,c,.\. EMPLOYEE #: DATE: ci ...1 .5- <br />Date Service Completed (if already completed): SERVICE CODE: 52_3 PI E: <br />Fee Amount: st-n, — Amount Paid ii-ge07) Payment Date 1/M..p <br />Receiv d By: (AW--- Payment Type ege jit Invoice # Check # /6 8--gs2_1+4(f„ <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003