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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID# SERVICE REQUEST# LAKEWOOD LIQUORS OD�U I OWNER/OPERATOR CHECK If BILLING ADDRESS GURINDER SINGH SAHOTA FACILITY NAME LAKEWOOD LIQUORS SITE ADDRESS 215 LAKEWOOD MALL LODI 95242 Street Number I Direction Street Name City Zip Code HOME or MAILING ADDRESS (If Different from Site Address) Street Number Street Name CITY STATE ZIP PHONE#1 EXT. APN# LAND USE APPLICATION# ( 916 ) 6672786 PHONE#2 EXT. BOS DISTRICT LOCATION CODE (209 ) 368 89-% 11 CONTRACTOR / SERVICE REQUESTOR REQUESTOR CHECK If BILLING ADDRESS BUSINESS NAME PHONE# EXT. LAKEWOOD LIQUORS 209 368 8956 HOME or MAILING ADDRESS FAX# 215 LAKEWOOD MALL ( ) CITY LODI STATE CA ZIP 95242 BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project specific ENVIRONMENTAL. HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as identified on this form. 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 COUNTY Ordinance Codes,Standards,STATE,and FEDERAL laws. APPLICANT'S SIGNATURE: "" Y �'� DATE: 01/22/2019 PROPERTY/BUSINESS OWNER© OPERATOR/NIANAGER ❑ OTHER AUTHORIZED AGENT❑ If APPLICANT is not the BILLING PARTY.proof of authorization to sign is required Title AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. PAYMENT TYPE OF SERVICE REQUESTED: RECEIVED COMMENTS: r-,- r (� � I^��Ip�,�(� t I _/� JAN 3 1 2019 SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT ACCEPTED BY: h EMPLOYEE#: DATE: ASSIGNED TO: EMPLOYEE#: DATE: Date Service Co leted (if already Completed): SERVICE CODE: 0 ( P I E: 12- Fee Fee Amount: . Amount Paid Payment Date 131 Payment Type SA.` Invoice# Check# Received By: EHD 48-02-02 17 01 I(n n 1�-?4 SR FORM(Golden Rod)