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San Joaquin County Environmental Health Department <br />Jamba <br />Site Address <br />Direction <br />Street Number <br />City State <br />Ext.APN #Land Use Application # <br />Ext.BOS District Location Code <br />CONTRACTOR / SERVICE REQUESTOR <br />Requestor Polo Padilla <br />Ext.Business Name David Scott Windle, Al A <br />) <br />75063StateZipCityTX <br />01.13.2023APPLICANT’S SIGNATURE: <br />Comments: <br />Date:Employee#:Accepted By: <br />Date:Employee#:Assigned to: <br />Payment DateFee Amount: <br />SR FORM (Golden Rod) <br />Phone#1 <br />( ) <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 />COUNT Y Ordinance Codes, Standards, STATE and FEDERAL laws. <br />EHD 48-02-025 <br />REVISED 11/17/2003 <br />Type of Business or Property <br />Jamba <br />Phone#2 <br />() <br />Golden Valley Parkway; Suite C <br />Street Name <br />Lathrop <br />___________City. <br />SERVICE REQUEST # <br />80086503 <br />95330 <br />Zip Code <br />Owner I Operator <br />Vitaligent-Norcal, LLC <br />Facility Name <br />SERVICE REQUEST <br />FACILITY ID # <br />Street Name <br />Zip <br />16460 <br />Street Number <br />Home or Mailing Address (if Different from site Address) <br />Phone# <br />(972 ) 457-2212 <br />Fax# <br />( <br />5|t^ ^-3 <br />bbl <br />Type of Service Requested: <br />Check if Billing Address <br />Check if Billing Address <br />Amount Paid ^4^. do <br />Check# <br />Irving <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 />do 7 <br />Service Code: <br />Home or Mailing Address <br />6201 Campus Circle Dr E <br />Received By: <br />Polo Padilla SHlgC. DATE: <br />Property / Business OwnerD Operator / Manager Ot her Authorized Agent El <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 environmental/site assessment <br />information to the San Joaquin Count y ENVIRONMENTAL Healt h Department as soon as it is available and at thj^ame time it is <br />provided to me or my representative. <br />Date Service Completed (if already completed): <br />_______________ <br />Payment Type C Invoice # <br />(£73^3 604 3 no ob