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1 <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> LAKEWOOD LIQUORS � ocib� �LA <br /> OWNER I OPERATOR <br /> CHECK If BILLING ADDRESS <br /> GURINDER SINGH SAHOTA <br /> FACILITY NAME <br /> LAKEWOOD LIQUORS <br /> SITE ADDRESS 215 LAKEWOOD MALL LODI 95242 <br /> Street Number I Direction Street Name City Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> ( 916 ) 6672786 <br /> PHONE#2 EXT" BOS DISTRICT LOCATION CODE <br /> (209 ) 3688956 <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> LAKEWOOD LIQUORS 209 ) 368 8956 <br /> HOME or MAILING ADDRESS FAX# <br /> 215 LAKEWOOD MALL ( ) <br /> CITY LODI STATE CA ZIP 95242 <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 /> 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 <br /> laws. <br /> APPLICANT'S SIGNATURE: L '5,41ol-4 DATE: 01/22/2019 <br /> PROPERTY/BUSINESS OWNER© OPERATOR/MANAGER ❑ OTHER ACITHORIZED AGENT❑ <br /> If APPLICA,VT 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 environmental/site 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 /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: <br /> ACCEPTED BY: �/It) EMPLOYEE#: DATE: <br /> ASSIGNED TO: V EMPLOYEE#: DATE: <br /> Date Service Co leted (if already completed): SERVICE CODE: ��,t P 1 E: No2 <br /> Fee Amount: , ' Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 19A a r► SR FORM(Golden Rod) <br /> REVISED 11/17/2003 K0 <br />