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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY IID# SERVICE REQUEST# <br /> Grocery Store �A (DC)) ti 9 <br /> OWNER/OPERATOR <br /> Bharpur Singh CHECK If BILLING ADDRESSO <br /> FACILITY NAME The Vineyard Shopping Center <br /> W Kettleman Ln. Lodi 95240 <br /> SITE ADDRESS 762 <br /> Street Number Direction Street Name Cit Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 9123 Harvest Hill Way <br /> Street Number Street Name <br /> CITY Elk Grove STATE ZIP <br /> CA 95624 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (925)6995796 <br /> PHONE#2 EXT. EMAIL BOS DISTRICT LOCATION CODE <br /> (925)9638797 rbntransportation@gmail.com <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> Bharpur Singh CHECK If BILLING ADDRESS <br /> BUSINESS NAME Indian Grocery Outlet PHONE# EXT• <br /> (925)6995796 <br /> HOME or MAILING ADDRESS 9123 Harvest Hill Way FAX# <br /> CITY Elk Grove STATE CA zIP 95624 EMA'r�ntransportation@qmail.com <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 or activity <br /> 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 a d FEDERAL la . <br /> APPLICANT'S SIGNATURE: DATE: 05/18/2023 <br /> PROPERTY/BUSINESS OWNER� OPERATOR/IffANAGER ❑ OTHER AUTHORIZED AGENT ❑ <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 site <br /> address,hereby authorize the release of any and all results,geotechnical data and/or environmental/site assessment information to the <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It IS available and at the Same time It Is pFgvided to me or my <br /> representative. AY <br /> TYPE OF SERVICE REQUESTED: / bnc <br /> Qwkuy' <br /> COMMENTS: <br /> SAN Jo Y 18 2023 <br /> AQUI <br /> HEgLTH HEPAR�NTY <br /> ENT <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: J DATE: Q/-2 <br /> i <br /> Date Service Completed (if already completed): SERVICE CODE: (0 P/E: 6 <br /> Fee Amount: �� Amount Paid 15& Payment Date S>'-7 23 <br /> Payment Type i�- Invoice# Check# k 3884-� Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 03/22/23 <br />