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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Convenience Store 0000. 7i S(�' © °�Z� <br /> r <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> Harbaksh Singh, Har reet Singh 4217 Green Knoll Rd Salida CA 95368 <br /> FACILITY NAME <br /> THE ACAMPO STORE <br /> SITE ADDRESS 3085' E ACAMPO RD ACAMPO 95220 <br /> Street Number Direction I Street Name City Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 4217 GREEN KNOLL RD <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> SALIDA CA 95368 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (209 ) 595-3391 013-200-06 <br /> PHONE#2 EXT. BOS DISTRICTLOCATION CODE <br /> (209 ) 345-0811 <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR Harbaksh Singh, Harpreet Singh (4217 Green Knoll Rd, Salida, CA) CHECK if BILLING ADDRESS <br /> BUSINESS NAMPHONE# Ex-r. <br /> E THE ACAMPO STORE 595-3391 <br /> HOME or MAILING ADDRESS FAX# <br /> 4217 Green Knoll Rd (209 )633-4619 <br /> CITY STATE ZIP 95368 <br /> SALI DA CA <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,Standards, STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: ffarbaXsh Sin h DATE: 05/05/2020 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER V 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 <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 JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and PA a time it is <br /> provided to me or my representative. R �N <br /> TYPE OF SERVICE REQUESTED: 5 ED <br /> COMMENTS: %I VIV 9 20 <br /> Change of ownership & renewal of health permit SAN'/04 ?� <br /> ItV C <br /> HEq TN()E 4 RIV L 7�, <br /> MENT <br /> ACCEPTED BY: EMPLOYEE M DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: <br /> Fee Amount: Amount Pa' /s�) (]� Payment Date 611 <br /> Payment Type Invoice# Check# o 1 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />