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• �v 1"�s 1 a\ 'vxa, <br /> r^gym �"r <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> J U N 0 " �6 SERVICE REQUEST <br /> Type of Business or Property FA CIL N ID# SERVICE REQUEST# <br /> Gas Station ENVIRONMENTAL HE) THf� <br /> 1 <br /> OWNER J OPERATOR <br /> CHECK if BILLING ADDRESS <br /> Mr. Singh <br /> FACILITY NAME Jahant Food & Fuel <br /> SITEADDRESS 2432 NHighway 99 Acampo 95220 <br /> Street Number Direction treat N=eZIP Cotle <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Sbeet Name <br /> CITY STATE ZIP <br /> PHONE#1 ErT APN# LAND USE APPUCATION# <br /> ( 209) 327-2836 <br /> PHONE#2 Err. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR Megan Mitchell CHECK If BILLING ADDRESS <br /> BUSINESS NAME Elite IV Contractors PHONE# Ems• <br /> 2091 461-6337 <br /> HOME or MAILING ADDRESS 2535 Wigwam Dr Fax# <br /> 9 (209) 461-6342 <br /> CITY Stockton STATE Ca ZIP 95205 <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: Mgq&v Mitchea DATE: <br /> : 6/7/2017 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENTLT Office Assistant <br /> IrAPPLTCANT 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: R0 <br /> COMMENTS: JL'/y ®, w DI <br /> co <br /> hc,yt HOBP,yRTT'IL tY <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: v� EMPLOYEE#: DATE: <br /> Date Service Completed Rif already Completed): SERVICECDW. Q P 1 E: � <br /> Fee Amount: f0a5,C50---rAmount Paid e, Payment Date 7 <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 ), O D 3 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />