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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 30 <br /> SERVICE REQUEST <br /> SERVICE REQUEST# <br /> Type of Business or Property FACILITY ID# <br /> Coffee Trailer Cn y7(M,lyl <br /> OWNER/OPERATOR <br /> WHITE CUP,INC.DBA AS CHECK If BILLING ADDRESS <br /> JAVA STOP <br /> FACILITY NAME <br /> SITE ADDRESS 17A EErIfffliFft Z'T V"- STOCKTON city 95203 <br /> Street Number Direction Street Name I Zip Code <br /> HOME or MAILING ADDRESS(If Different from Site Address) 321 SHUTCHINS STREET <br /> Street Number Street Name <br /> CITY LODI STATE CA ZIP <br /> 95240 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (209 1369-9384 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> (209 )329.7712 <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR KELLY RAY BROWN ►jj <br /> CHECK If BILLING ADDRESS'`' <br /> BUSINESS NAME JAVA STOP PHONE# EXT. <br /> (209 )369-9364 <br /> HOME or MAILING ADDRESS 321 S HUTCHINS STREET FAx# <br /> ( 1 <br /> CITY LODI STATE CA ZIP 95240 <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 /> 1 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, STA7 and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: /L//0A'CJ <br /> PROPERTY/BUSINESS OWNERS dgATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> If APPLICANT is not the BILLING PARTY proef of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASED ORMTLM: 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 JOAQUTN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. �w <br /> TYPE OF SERVICE REQUESTED: - e;� r I,e (Z' " W V I O /NTT��JMNT CID <br /> COMMENTS: RECEIVED <br /> ED <br /> DEC 10 2020 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: CCI-V d. C EMPLOYEE#: DATE: i-7 -(O - ?,tASSIGNED TO: ?16 <br /> f.'( LIACA—i EMPLOYEE# \I: DATE: — —C 0 --2-� <br /> Date Service Completed(if already completed): SERVICE CODE: O( P I E: &oar <br /> Fee Amount: 2 Amount Paid 5—Z Payment Date <br /> Payment Type c Invoice# Check# 8 6 Received By: <br /> U <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 3`1 <br />