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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Grocery Store <br /> OWNER/OPERATOR <br /> Pacific Constanzo Lewis PTP CHECK If BILLING ADDRESS <br /> FACILITY NAMES afeway Store #1648 <br /> SITE ADDRESS w Kettleman Lane Lodi 95242 <br /> 2449 Street Number I Dire Street Name city Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) Oakland Blvd <br /> 1371 Street Number Street Name <br /> ClTywalnut Creek STATE CA ZIP 94596 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> ( 209) 367-7875 027-410-050-000 <br /> PHONE#2 ECT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> Kasey Peterson CHECKIf BILLING ADDRESS <br /> BUSINESSNAME Cuhaci & Peterson PHONE# Ear. <br /> HOME or MAILING ADDRESS FAx# <br /> 930 Woodcock Road ( ) <br /> CITY Orlando STATE FL ZIP 32803 <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,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> /� �CtFllQQ6L 10/5/21 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER OTHER AUTHORIZED AGENT CR Pprmi nn-rdinat= <br /> If APPLICANT is not the BILLING PARTY proof of authorization t0 sign is required Titre <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, 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 atpr�s�,e�time it is <br /> provided to me or my representative. t tV/ <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: <br /> S <br /> 4FD0A/11V )y <br /> EPgRTMF <br /> ACCEPTED BY: EMPLOYEE DATE: D 15 ;-1 <br /> ASSIGNEDTO: r \WIT I <br /> EMPLOYEEM IO DATE. I 15 hZI <br /> Date Service Completed (If already completed): SERVICE CODE: a- PI E: <br /> Fee Amount: u Amount Pai l �,�� Payment Date <br /> Payment Type !�_ Invoice# Check# �'7/S Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />