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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> JUN 0 7 NERVICE REQUEST <br /> Type of Business or Propertyr. FACIL TY ID# SERVICE REQUEST# <br /> Gas Station ENVIRONMENTAL H� TH ��)1311} 5 S !1'1i 7(a l <br /> OWNER/OPERATOR J CHECK it BILLING ADDRESS❑ <br /> Mr. Singh <br /> FACILITY NAME Jahant Food & Fuel <br /> SITEADDRESS 2432M Highway 99 Acampo 95220 <br /> street Number Directiun Street Name city ZloCod. <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> street Number street Name <br /> CITY STATE zip <br /> PHONE#1 LAND USE APPLICATION# <br /> ( 209) 327-2836 <br /> PHONE S2 En. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> Megan Mitchell CHECK(}BILLING ADDRESS <br /> BUSINESS NAME Elite IV Contractors PHONE# Ems' <br /> 205 461-6337 <br /> HOME Or MAILING ADDRESS 2535 Wigwam Dr FAX# <br /> (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 Rod 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: Megan WcheU DATE: <br /> 6/7/2017 <br /> ❑ L <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER OTHER AUTHORIZED AGENT T Office Assistant <br /> If APPL/CANT is nor the BILUNG PARTY proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1,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. Ap A, <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: <br /> O � ?0 <br /> NFA�DppA4l a�/V <br /> ACCEPTED BY: MPLOYEE M DATE: <br /> AsSIGNEDTO: v� EMPLOYEE#: DATE: <br /> Date Service Completed If already completed): SERVICE CODE: Q P 1 E: Jll% <br /> Fee Amount: v Amount Paid �f S 57'-� 1 Payment Date <br /> Payment Type i/Mik I Invoice# Check# Received By: f4 <br /> EHD 4&02-025 k 1 I 1 O O 7J SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />