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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Existing BP/Arco#7049 <br /> OWNER/OPERATOR <br /> Shopco USA, Inc CHECK if BILLING ADDRESS <br /> FACILITY NAME Existing BP/Arco#7049 <br /> SITE ADDRESS 800 E Kettleman Ln. Lodi 95240 <br /> Street Number I Direction Street Name city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> ( ) <br /> PHONE#2 EXT• BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR Richard Dugie CHECK if BILLING ADDRESS <br /> BUSINESS NAME Dugie Design Group, LLC PHONE# Exr. <br /> 425 492-4159 <br /> HOME or MAILING ADDRESS FAx# <br /> 717 191st PI SW f ) <br /> CITY Lynnwood STATE WA ZIP 98036 <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,Stands , TATE and FEDERAL laws. <br /> APPLICANT'S SIGNATU DATE: 01/15/19 <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER D OTHER AUTHORIZED AGENT® Principal <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 t���e_Isssment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the sa�""�Tse <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: Replace and install new coffee equipment,Add a new food case and install a new air curtain sqV <br /> Oq <br /> N�CTH p�pM FN��N <br /> RT,yFN <br /> ACCEPTED BY: C. ,/ EMPLOYEE#: DATE: 17-- <br /> ASSIGNED TO: ji� at�at . EMPLOYEE#: DATE: 7 ✓ / <br /> i' _ <br /> Date Service Completed (if already completed): SERVICE CODE: ,�, Z P 1 E: C <br /> Fee Amount: ,l --� Amount Paid Payment Date !7 <br /> Payment Type Invoice# Check# l�S� Rece ve By: 3�::J <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />