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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Recreational F--ft 002`psb� SR0047043 <br /> OWNER/OPERATOR <br /> Elysia Garcia CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> Lake Front Resort <br /> SITE ADDRESS 12 West Lorenzen Rd. TT 95304 <br /> Street Number Direction Street Name Ctt cy Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) North Naglee Rd. <br /> 2455 <br /> Street Number Street Name <br /> CITY Tracy STATE Ca ZIP 95304 <br /> PHONE#1 ExT. APN# LAND USE APPLICATION# <br /> ( 209) 640-4252 <br /> PHONE#2 ExT. EMAIL BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> Lovepreet Singh CHECK if BILLING ADDRESS <br /> BUSINESS NAME Lake Front Resort PHONE# 640-4252 ExT. <br /> HOME or MAILING ADDRESS FAX# <br /> 2455 North Naglee Rd. ( ) <br /> CITY STATE CA ZIP 95304 EMAIL <br /> Tracy info@lakefrontresort.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 /> 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 /> 08/08/2023 <br /> APPLICANT'S SIGNATURE: � �J' Art4"' DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER R1 OTHER AUTHORIZED AGENT ❑ <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 above site <br /> address, hereby authorize the release of any and all results,geotechnical data and/or environmental/site assessment information to the <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the Same time It Is provided to me or my <br /> representative. <br /> TYPE OF SERVICE REQUESTED: e C" PAYMENT RECEIVp <br /> COMMENTS: <br /> AUG 0 8 202 <br /> SAN 40AGUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: �; ^ ` Q EMPLOYEE#: DATE: QV . 2 <br /> ASSIGNED TO: EMPLOYEE#: DATE: , 2- <br /> Date <br /> Date Service Completed (if already completed): SERVICE CODE: OI_ 1 P/E: <br /> Fee Amount: , b 2 Amount Paid Payment Date ( , 2 <br /> Payment Type f Invoice# I ftz I <br /> Check# Received By: <br /> ko C S� <br /> EHD 48-02-025 y S22 SR FORM(Golden Rod) <br /> 03/22/23 <br />