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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 /> i l:� 00 -Z Skoogcj 1-70 <br /> OWNER/OPERATOR <br /> AMARPREET SINGH CHECK if BILLING ADDRESS❑ <br /> FACILITY NAME <br /> INDIAN MARKET <br /> SITE ADDRESS 15104 S HARLAN RD LATHROP 95330 <br /> Street Number I Direction I Street Name city Zip Cod. <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 /> ( 209 )6874500 <br /> PHONE#2 Exr. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTDR AMARPREET SINGH CHECKlf BILLING ADDRESS❑ <br /> BUSINESS NAME PHONE# Ext' <br /> INDIAN MARKET 209 328-3232 <br /> HOME or MAILING ADDRESS 15104S HARLAN RD, LATHROP, CA 95330 FAxIf <br /> I ) <br /> CITY LATHROP STATE CA ZIP 95330 <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: �h(Cr�j/02¢2Z`c�ulG DATE: 03/29/2022 <br /> PROPERTY/BUSINESS OWNER® OPERATOR/MANAGER OTHER AUTHORIZED AGENT❑ <br /> lfAPPLICANT is nol 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. 1— <br /> TYPE OF SERVICE REQUESTED: Q>,�(�Q,/ .` Gy \t^� RECEIVE <br /> COMMENTS: <br /> T 1OA01NN GOONI't <br /> aP ENVIRONMENTAL <br /> MENI <br /> "'TN�e„pT <br /> ACCEPTED BY: r1��!Q EMPLOYEE M DATE: l— l v <br /> ASSIGNED TO: L�n r \o e EMPLOYEE#: DATE: kA —16- 2 <br /> Date Service Completed (If already Completed): SERVICE CODE: OI 1 PIE: bD <br /> Fee Amount: 1 5 2 Amount Paid 1S2-, Payment Date <br /> Payment Type L�r�� Invoice# 15bel6k# !{ Z L� SR Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />