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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />BUSINESS NAME <br />SERVICE REQUEST # <br />Grocery Store <br />(312) 956-4092 <br />HOME or MAILING ADDRESS <br />FAx # <br />OWNER / OPERATOR <br />CHECK If BILLING ADDRESS <br />Keevin Simpson <br />SAN JOAQUf <br />FACILITY NAME <br />Sprouts Farmers Market <br />SITE <br />olden Valley Parkway <br />EMPLOYEE#: 6213 <br />Lathrop <br />95330 <br />165576 Street Number <br />Directlon <br />Street Name <br />DATE: 12-14-21 <br />Cil <br />Z Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />523 <br />P I E: 1601 <br />Street Number <br />Amount Pal <br />Street Name <br />CITY <br />STATE ZIP <br />PHONE #1 EXT. <br />APN # <br />LAND USE APPLICATION # <br />1312/956-4092 <br />PHONE #2 Ea. <br />BOS DISTRICT <br />LOCATION CODE <br />(310)808-5046 <br />11 <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />Leif Erickson Email: LRE@Lampertgroup.build CHECK if BILLING ADDRESS <br />BUSINESS NAME <br />PHONE # Em. <br />Lampert Group LLC <br />(312) 956-4092 <br />HOME or MAILING ADDRESS <br />FAx # <br />10061 Riverside Dr. #760 <br />( ) <br />CITY Toluca Lake STATE CA ZIP 91602 <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 />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 <br />yand <br />.FEDERAL laws. <br />APPLICANT'S SIGNATURE: v DATE: 12/10/21 <br />PROPERTY/ BUSINESS OWNER ❑ OPERATOR/MANAGER❑ OTHER AUTHORIZED AGENT® Representative <br />If APPLICANT is not the BILLING PAR TP proof of authorization to sign is required 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 environmental/site assessment <br />information t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time It IS <br />provided to me or my representative. <br />TYPE OF SERVICE REQUESTED: Grocery Store Plan Review <br />AYME <br />COMMENTS: <br />' VED <br />DEC 14 2021 <br />SAN JOAQUf <br />HEALTH DEAEN7ALTY <br />ACCEPTED BY: Vidal PedraZa <br />EMPLOYEE#: 6213 <br />DATE: 12-14-21 <br />ASSIGNED TO: Kadeanne Llnhares <br />EMPLOYEE#: 4589 <br />DATE: 12-14-21 <br />Date Service Completed (If already completed): <br />SERVICE CODE: <br />523 <br />P I E: 1601 <br />Fee Amount: 456 <br />Amount Pal <br />T56.OV <br />Payment Date <br />Payment TypeA1C `—t— <br />Invoice # <br />Check # 134 <br />Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11117/2003 <br />