Laserfiche WebLink
Type of Business or Property <br />Convenience Store <br />Owner I Operator <br />Rivergate Wine & Spirits, Inc <br />Facility Name <br />Rrvenjate Wine & Spints, Inc <br />Site Address Turner Road Lodi <br />Street Name City <br />Street Number <br />City State <br />Ext.APN #Land Use Application # <br />3?1-0628 <br />Ext.BOS District Location Code <br />CONTRACTOR / SERVICE REQUESTOR <br />Requestor <br />Ext. <br />Rivergate Wine & Spirits, Inc.321-0628 <br />City State ZipLodi 95240Ca <br />APPLICANT’S SIGNATURE: <br />Type of Service Requested: <br />Comments: <br />2-27-24Vidal Pedraza Date:Employee#:6213Accepted By: <br />9838 2-27-24Date:Employee#:Francisco RuizAssigned to: <br />P/E: 1601523Service Code:Date Service Completed (If already complatod): <br />486Fee Amount: <br />Payment Type V Invoice # <br />payment 177120513 SR FORM (Golden Rod)EHD 48-02-025 <br />REVISED 11/17/2003 <br />209 <br />Phone #2 <br />( 209 ) 321-0630 <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 perfonned will be done in accordance with all San Joaquin <br />County Ordinance Codes, Standards, &K\TE and Federal laws. <br />plan review <br />electronic <br />95240 <br />Zip Coda <br />Phone #1 <br />( ) <br />SERVICE REQUEST # <br />108 <br />Street Number <br />San Joaquin County Environmental Health Department <br />SERVICE REQUEST <br />FACILITY ID # <br />West <br />Direction <br />Home or Mailing Address (if Different from site Address) <br />Street Nnmg <br />Zip <br />Payment Date <br />777/73573 Received By: — <br />Inderjit "Andy" Kang <br />Business Name <br />Check# <br />Amount Paid <br />Check If Billing address SI <br />Check If Billing Address El <br />________________________________________________ I)ATE:t <br />Property / Business Owner El Operator / Manager D Other Authorized Agent EJ <br />If Applicant is not the Hilling 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 enviromnental/sitc assessment <br />information to 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 />FEB 2 7 2024 <br />Phone # <br />( 209 ) <br />Fax# <br />() <br />Home or Mailing Address 108 West Turner Road