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flee"Ofe <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />CHECK if BILLING ADDRESS <br />SERVICE REQUEST # <br />Grocery Store <br />PHONE# EXT. <br />Lampert Group, LLC <br />�kfoov5ILP <br />OWNER/ OPERATOR <br />FAX# <br />Sprouts Farmers Market Inc <br />CHECK if BILLING ADORESSl�I OI� <br />FACILITY NAME <br />STATE CA ZIP 91602 <br />Sprouts Farmers Market <br />SITE ADDRESS 5308 <br />Pacific Avenue <br />Stockton <br />95207 <br />Street Number <br />Direction <br />Street Name <br />city <br />Zip Code <br />HOME Or MAILING ADDRESS (If Different from <br />Site Address) <br />Street Number <br />Street Name <br />CITY <br />STATE ZIP <br />PHONE#1 En. <br />APN# <br />LAND USE APPLICATION# <br />(312)956-4092 <br />1 102-240-160 <br />PHONE #2 En. <br />( ) <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />Sprouts Farmers Market, Inc - Leif Erickson (Agent) <br />CHECK if BILLING ADDRESS <br />BUSINESS NAME <br />PHONE# EXT. <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 <br />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 />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: � DATE: 4/13/22 <br />PROPERTY/BUsINEss OWNER❑ OPERAT R/MANAGER ❑ OTHER AUTHORIZED AGENTV Permitting Agent <br />IfAPPLICANT 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 environmentaUsite assessment <br />information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and F t�lhe same time it is <br />provided to me or my representative. ZA yn/)n <br />TYPE OF SERVICE REQUESTED: Environmental Health Plan Review <br />COMMENTS: electronic expedited AP <br />NJ API? 14 <br />S4 <br />hECO <br />AL04 <br />Ty fpgRTOPN <br />MFNTy <br />ACCEPTED BY: Vidal PedraZa EMPLOYEE#: 6213 DATE: 4-13-22 <br />ASSIGNED TO: Vidal PedraZa I EMPLOYEEM 6213 1 DATE: 4-13-22 I <br />Date Service Completed (If already completed): SERVICE CODE: 523 I P / E: 1601 <br />Fee Amount: 684 Amount Paid If> /, A4 /Yl Payment Date / 4 <br />Payment Type 1 / j<, I Invoice # I Check # 14 / aZ-7G/A-2, I Receided By: /P J <br />EHD 48-02-025 payment confirmation 141437903 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />