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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />Bakery <br />FACILITY ID # <br />7- 1 ( q <br />SERVICE REQUEST # <br />,-.))Ct)()B--4- 3S-3 <br />OWNER / OPERATOR Cory Smith CHECK if BILLING ADDRESS <br />FACILITY NAME Lakeside Bakery <br />SITE ADDRESS 2233 <br />Street Number Direction <br />Grand Canal Blvd, Suite 102 <br />Street Name <br />Stockton <br />City <br />95207 <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Street Number Street Name <br />CITY STATE ZIP <br />PHONE #1 Ex-r. <br />( 916 1 224-5969 <br />APN # <br />110-110-060 <br />LAND USE APPLICATION # <br />PHONE #2 Ex-r. <br />( 1 <br />EMAIL BOS csmith@SteelCityCommercial.com DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR Stacey Wellnitz CHECK if BILLING ADDRESS 61 <br />BUSINESS NAME Commercial Arch PHONE # EXT. <br />( 209 )571-8158 <br />HOME or MAILING ADDRESS 616 14th St. <br />FAX # <br />( ) <br />CITY Modesto STATE CA ZIP 95354 EMAIL plancheck@commercialarch.com <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 or activity <br />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: <br /> <br />DATE: 10/17/2023 <br /> <br />PROPERTY / BUSINESS OWNER 0 OPERATOR / MANAGER 0 OTHER AUTHORIZED AGENT IZI <br />If APPLICANT IS not the BILLING PARTY, proof of authorization to sign is required <br />Architect <br /> <br />Title <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above site <br />address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment formation to the <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is pro or my <br />representative. <br />-%NZIllifE*15 TYPE OF SERVICE REQUESTED: 7\1 ‹...4.) ,.._.-,k--•,•-7 / -4-- , LiCi <br />COMMENTS: SAN 423 Jaqr, <br />411/R wti1N C ife40., 04,44, °um., <br />r7 o47„,,,Nr44 • r <br />`1,174/4.417. <br />ACCEPTED BY: (y--,4_ e Sc_.=,. EMPLOYEE #: DATE: <br />ASSIGNED TO: (:?x , EMPLOYEE #: DATE: 7 2 3 ( <br />Date Service Completed (if already completed): SERVICE CODE: 5 2_,::3 PI / (,b/ <br />Amount Paid <br />14 3t.o. Payment Date 1 012_5-12 3 Fee Amount: 4--.6, <br />Payment Type (1,--a 4 0p Invoice # elleekk I-1_ ( u.c2, -fa( 2.A Received By <br /> <br />?go 5 056111 <br />EHD 48-02-025 SR FORM (Golden Rod) <br />03/22/23