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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUES��Trr# <br /> Coffee House (Z (���c1/ `t <br /> OWNER/OPERATOR <br /> Dutch Bros Coffee CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> Dutch Bros Coffee- Lodi <br /> SITE ADDRESS 2602 W I Kettlemen Lane Suite#110 Lodi 95242 <br /> Street NumEer DIMIIon Street Name CIty Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 12884 Simpson Ranch Court <br /> Street Number Street Name <br /> CITY VViilton STATE CA ZIP 95693 <br /> PHONE#1 ExT. APN# LAND USE APPLICATION# <br /> PHONE#2 EXT BOS DISTRICT <br /> LOCATION CODE <br /> l I Z <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR Architect <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME iT Archftecture, Inc. PHONE# E> . <br /> 559 442-4642 <br /> HOME or MAILING ADDRESS 1465 N. Van Ness Avenue FAX# <br /> CITY Fresno STATE CA ZIP 93728 <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,Standar EDERAL laws. 1 <br /> APPLICANT'S SIGNATURE: DATE: '3t'1_ \ZQ(`a <br /> PROPERTY/BUSINESS OWNER❑ PERATOR/MANAGER ❑ OTHERAUTH DAGE.NT® Vice-President <br /> ifAPPL/CANT 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 environmentalisite 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: ' <br /> COMMENTS: D <br /> `C Sav, 2 j 2018 <br /> N TH EpgR 0 7y <br /> ACCEPTED BY: �`(-`�(SSG EMPLOYEE#: DATE: 5 �/1 p <br /> ASSIGNED TO: V1,('t f EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: Z3 P/E: / 1rU <br /> Fee Amount: ,Grp Amount Paid T� Payment Date <br /> Payment Type X35 Invoice# Ch Ince ved By: <br /> EHD 48-02-025 f, r 1 <br /> SR FORM(Golden Rad) <br /> REVISED 11/17/2003 f i� ,,ry GY4C)t Eh�T <br />