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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # SERVICE REQUEST # <br /> Retail fueling station 7 606 7� 941 00 5 085 <br /> OWNER / OPERATOR <br /> Lodi 76 , Jivtesh Gill CHECK if BILLINGADDRESSE] <br /> FACILITY NAME Lodi 76 <br /> SITE ADDRESS 1111 E Kettleman Ln . Lodi 95240 <br /> Street Number 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 #'I ExT• APN # LAND USE APPLICATION # <br /> (209) 948 -2438 <br /> PHONE #2 ExT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR James Otto CHECK If BILLING ADDRESS <br /> BUSINESS NAME LC Services PHONE # ExT, <br /> 55 444 - 1730 <br /> HOME or MAILING ADDRESS FAX # <br /> 3887 N Valentine Ave ( ) <br /> CITY Fresno STATE CA ZIP 93722 <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 <br /> 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 : James Otto DATE : 3/21 /2022 <br /> PROPERTY / BUSINESS OWNER El OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT ® Project Coordinator <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 <br /> site address , hereby authorize the release of any and all results , geotechnical data and/or er inmental/site assessment information <br /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available . at the same time it is provided to me or <br /> my representative . P <br /> TYPE OF SERVICE REQUESTED : � 7� <br /> COMMENTS: O <br /> SqN MAR 3 1 ?0?? <br /> NEgRONkNCOU <br /> LT <br /> H pEpq �� Ty <br /> ACCEPTED BY: EMPLOYEE M DATE : .31 <br /> ASSIGNED TO : V / e kii <br /> /J /n EMPLOYEE #: DATE : <br /> Date Service Completed I(already competed ) : SERVICE CODE : / G Z,,J� PIE: 'Zoo? <br /> Fee Amount: ` !J� da Amount Pai L� OD Payment Date 7 3 / <br /> Payment Type Invoice # Check # Received By : <br /> EHD 48-02-025 SR FORM (Golden Rod) <br /> 07/17/08 <br />