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SAN JOA(R) IN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # /SERVICE RYEIQUEST # <br /> Retail � a003 � � �IqG ��`I <br /> OWNER / OPERATOR Rupi Padda <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME Flame Llquors - - <br /> SITE ADDRESS 1301 West Kettleman Lane Lodi 952040 <br /> Street Number Direction I Street Name city Zip Code <br /> HOME or MAILING ADDRESS (if Different from Site Address) <br /> SAME Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE #1 EXT, APN # LAND USE APPLICATION # <br /> ( 209 ) 334-3233 03 i J q03� <br /> PHONE #2 EXT, BOS DISTRICT LOCATION CODE <br /> 712-7359 <br /> ( 209 ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> Carrie Miller CHECK If BILLING ADDRESSIZ <br /> BUSINESS NAME Elite IV Contractors PHONE # EXT, <br /> 209)461 -6337 <br /> HOME or MAILING ADDRESS FAX <br /> 2535 Wigwam Dr ( ) <br /> CITY Stockton STATE CA ZIP 95205 <br /> BILLING ACKNOWLEDGEMENT: 1 , 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 <br /> activity will be billed to me or my business as identified on this form . <br /> also certify that I have preparards,01 <br /> plication and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes , StafATE and FEDE aws. <br /> APPLICANT' S SIGNATUR ( �G DATE : 1 /5/2022 <br /> PROPERTY I BUSINESS OWNER ❑ OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT ® Office Manager <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 <br /> site address , hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information <br /> 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 <br /> my representative . � <br /> TYPE OF SERVICE REQUESTED: fit S T P" i or l tjp <br /> COMMENTS : I V,�� <br /> Sq N �AN <br /> EWv/ <br /> QU/N C <br /> NEqcTH�Ep " TAL <br /> ACCEPTED BY : (�• y/ f�- EMPLOYEE # : DATE : ��' T <br /> �43ASSIGNED TOO . `C L� !J <j ' EMPLOYEE M DATE: <br /> Date Service Completed (if already completed) : LL SERVICE CODE: I �` �e7, F PIE: 6q <br /> I <br /> Fee Amount: h/ ,s2 � Amount P �5� � O � Payment Date 27 <br /> Payment Type ' `S'' Invoice # Check # 13 (, 51 ,3375= Received By: <br /> EHD 48-02-025 SR FORM (Golden Rod ) <br /> 07/17/08 <br />