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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE <br /> -7REQUEST# <br /> Independent Senior Living Apartment FA0000258 S g4 1 <br /> OWNER I OPERATOR <br /> Lodi Commons 2022, LP CHECK If BILLING ADORESS� <br /> FACILITY NAME <br /> Arbor Senior Livia <br /> SITE ADDRESS 115 Louie Avenue Lodi 95240 <br /> Street Number Direclon I Street Name Zip Code <br /> HOME or MAILING ADDRESS (It Different from Site Address) 550 Howe Avenue Ste. 100 <br /> Street Number 5 a o <br /> CITY Sacramento STATE CA ZIP 95825 <br /> PHONE#1 EKT• APN# LAND USE APPLICATION# <br /> ( 916 ) 649-7500 041-250-390-000 <br /> PHONE#2 FXT. BOIS DISTRICT LOCATION CODE <br /> ( 1 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> Amanda Hutchins CHECK if BILLING ADDRESS❑ <br /> BUSINESS NAME PHONE# En.Knox,Lemmon & Anapolsky,LLP 916)498-9911 <br /> 234 <br /> HOME or MAILING ADDRESS FAx# <br /> 2339 Gold Meadow Way, Suite 205 ( 916)498-9991 <br /> CITY Gold River STATE CA Zip 95670 <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 <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: UV\ OnAokt �1-C' o >`n - ', DATE: II � OIr1DC <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHERAUTHOREzEDAGENT© Attorney <br /> 0'-{L„ JU:nk t^ <br /> If APPLICANT is 1101 the BILLING PARTY proofofanthorizatioNlosigiiisrequirerl Title <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 environmentaUsite assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available andPIlry maple time it is <br /> provided to me or my representative. �`1 TM <br /> TYPE OF SERVICE REQUESTED: VE <br /> COMMENTS: <br /> AN 19 <br /> 24?? <br /> SAIV JOA <br /> Hfe1VTHOEPgRTM NTY <br /> NT <br /> ACCEPTED BY: EMPLOYEE#: I DATE; Zy <br /> ASSIGNED TO: EMPLOYEE#: I L DATE: ZZ <br /> Date Service Completed 6f already completed): SERVICE CODE: IE: if 00 <br /> Fee Amoun �u Amount Paid-?? Payment Date <br /> Payment Type lam, 1 Invoice# Check# /37S3S7/ Recelved By: <br /> EHD I ^ SR FORM(Golden Rod)REVISED 11/172003 3Z <br />