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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Indoor Play Place eg 10—� <br /> OWNER/OPERATOR <br /> Jim&Kelli Powell CHECK If BILLING ADDRES <br /> FACILITY NAME <br /> Gingerbugs <br /> SITE ADDRESS 2 West Oak Lodi 95240 <br /> Street Number Direction Street Name city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) Crystalwood Lane <br /> 1919 Street Number Street Name <br /> CITY STATE ZIP <br /> Lodi CA 95242 <br /> PHONE#1 EXT• APN# LAND USE APPLICATION# <br /> ( 209 ) 747-1198 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( 209 ) 224-8684 <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> Jim Powell CHECK If BILLING ADDRESS <br /> BUSINESS NAME Gingerbugs PHONE# ExT. <br /> HOME or MAILING ADDRESS FAX# <br /> CITY STATE ZIP <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,Standards,STATE and,,FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: 08/15/19 <br /> PROPERTY/BUSINESS OWNER® OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <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 COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: �ek4l " <br /> COMMENTS: L <br /> �— <br /> j'1bit S 1 D�r <br /> ✓J � J <br /> ACCEPTED BY: V T <br /> EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: �(• 6 DATE: <br /> Date Service Completed If already completed): SERVICE CODE: P I : 1 60 <br /> Fee Amount: Amount Paid /P Payment Date <br /> Payment Type S A Invoice# Check# , Received By: L6 <br /> EHD 48-02-025 q5 D SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />