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IN 0 s-,1q0a,ci SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property Mercantile FACILITY ID # SERVICE REQUEST # OWNER/OPERATOR CHECK if Five Below, Inc. BILLING ADDRESS FACILITY NAME Five Below SITE ADDRESS 2350 Street Number W Direction Kettlemann Ln Street Name Lodi City 95242 Zip Code HOME or MAILING ADDRESS (If Different from Site Address) 701 Street Number Market St Ste 300 Street Name CITY STATE ZIP Philadelphia PA 19106 PHONE #1 EXT. (817 ) 876-7175 APN # 058-140 -350 -000 LAND USE APPLICATION # PHONE #2 Err. (215 ) 207-2586 BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR Shannon Loucks CHECK if BILLING ADDRESS BUSINESS NAME State Permits Inc PHONE # (406) Err 897-0786 HOME or MAILING ADDRESS 319 Elaines Ct FAX # ( ) CITY Dodgeville STATE W I ZIP 53533 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 hourly 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, ST ATE and FEDERAL laws. APPLICANT'S SIGNATURE: DATE: 08-11-23 PROPERTY / BUSINESS OWNER 0 OPERATOR / MANAGER 0 OTHER AUTHORIZED AGENT El Permit Consultant 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. TYPE OF SERVICE REQUESTED: ,p6 1.1 (NeAr eXa ci0 eb-46PU`1")— la 6 4;5 riyi -.1v A , ce l ,, COMMENTS: Plan Check v''z / 9 2923 SAN %JO 14 4fri 4 QU/N 11D6P4h1/71741:4 Z")' ACCEPTED BY: cc,uv-vr,A c.. c_o EMPLOYEE#: E'Nr DATE: ,10 , 1 1, .-- ...........3 ASSIGNED TO: EMPLOYEE #: DATES" ..-- 14. --- ".._•3 Date Service Completed (if already completed): SERVICE CODE: S-4-273 PIE: 1 60( Fee Amount: A. L. . crb 4.9 Amount Paict /.1- $ . ( e)() Payment Date Payment Payment Type , .,,,_ Invoice # Check # Received By: EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003