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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property DOD FACILITY ID # SERVICE REQUEST It OWNER/OPERATOR Chelsea Young CHECK if BILLING ADDRESS çI FACILITY NAME Lathrop Food Plaza • SITE ADDRESS 16201 Street Number Direction S harlan Rd Street Name Lathrop City 95330 Zip Code HOME or MAILING ADDRESS (If Different from Site Address) 3311 Salvatore In Street Number Street Name CITY STATE Stockton CA ZIP ot 's -- 9531J PHONE #1 EXT. (209) 319-3549 APN # LAND USE APPLICATION # PHONE #2 EXT. ( 209)319-3522 BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR CHECK if BILLING ADDRESS BUSINESS NAME PHONE # ( ) EXT. HOME or MAILING ADDRESS FAX # ( ) CITY STATE ZIP BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT houtly charges associated with this project or activity will be billed to me or my business as identified on this form. 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 COUNTY Ordinance Codes, Standards, STAT4nd FEDERAL laws. APPLICANT'S SIGNATURE: DATE: 02/07/24 PROPERTY/ BUSINESS OWNER'S' OPERATOR / MANAGER 0 OTHER AUTHORIZED AGENT 0 If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required Title AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. - • iv TYPE OF SERVICE REQUESTED: REcE'tNT COMMENTS: Ft8 0 7 play review SAN Jo A 2024 electronic HEAVV/f8 1-8N Co AL TH 0 N/14 A/T UNTy EpA ,,,,,. At. ' s i 11,ZN 7. ACCEPTED By: . Vidal Pedraza EMPLOYEE #: 6213 DATE: 2-7-24 ASSIGNED TO: Kadeanne Linhares EMPLOYEE #: 4589 DATE: 2-7-24 Date Service Completed (if already completed): SERVICE CODE: 523 PIE: 1601 Fee Amount: 486 Amount Paid # /4 -Z.... cC) Payment Date Payment Type Type 1 6 i 4--- Invoice # Check # 176 00230..1_ Received By: SR FORM (Golden Rod) • Payment 176002364 EHD 48-02-025 REVISED 11/17/2003