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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Food demonstrations/samples SQ DD'gl-4G li S <br /> OWNER/OPERATOR <br /> Club Demonstration Services Inc. CHECK If BILLING ADDRESS <br /> FACILTYNAME Club Demonstration Services Inc. <br /> SITE ADDRESS 2680 Reynolds Ranch Pkwy Lodi 95240 <br /> Street Number Direction Street Name City Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 15310 Barranca Parkway- Suite 100 <br /> Street Number Street Meme <br /> CITY Irvine STATE CA ZIP 92618 <br /> PHONE#1 E'T' APN# N/A LAND USE APPLICATION# N/A <br /> ( 940) 295 7135 <br /> PHONE#2 N/A Ew. BOS DISTRICT N/A LOCATION CODE <br /> ( ) N/A <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR Club Demonstration Services Inc. CHECK if BILLING ADDRESS <br /> BUSINESS NAMEPHONE# Eur• <br /> Club Demonstration Services Inc. 940 1 295 7135 <br /> HOME Or MAILING ADDRESS 15310 Barranca Parkway-Suite 100 (A%# ) N/A <br /> CITY Irvine STATE CA LP 92618 <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 ENvfRoNMENTAL 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: Sy&anr ReU W4iyice CDDd(ylG tot DATE: 11/17/2021 <br /> 0 <br /> PROPERTY/BUSINESS OWNER El OPERATOR/MANAGER ❑ OTHER AtTTHORIZEDAGENT Compliance Coordinator <br /> (APPLICANT is not the BILLLNc 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: PAYMENT <br /> COMMENTS: <br /> Club demonstrations services at costco. 0 22 202 <br /> .AN JOAOUINCOUMn <br /> "WONMENN"M <br /> HEALTH DEPA <br /> EW <br /> ACCEPTEDBY: Vidal PedraZa EMPLOYEE#: 6213 DATE. 11_19-21 <br /> ASSIGNEDTO: Daria Afonskala EMPLOYEE#: 9825 DATE: 11-19-21 <br /> Date Service Completed (if already Completed): SERVICE CODE: 061 PIE: 1602 <br /> Fee Amount: 152 Amount Paid e 5 Payment Date <br /> Payment Type S Invoice# Check# / Received By: <br /> EHD 48-02-025 Payment confirmation# 134928653 p / 2,V t., I SR FORM(Golden Rod) <br /> REVISED 11/17/2003 9PA9AI31Z _hlll li <br />