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ViEV-1Wb. <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH t EIPA> �MENT� L E COPY <br /> SERVICE REQUEST <br /> Type of Business or Property FACILIT"V1 R N ICE REQUEST# <br /> Gas Station - Mini Mart s C 7-2 <br /> OWNER/OPERATOR <br /> Joe Jinger Lou CHECK if BILLING ADDRESS <br /> FACILITY NAME <br /> Food Mart <br /> SITEADDRESS 2185Fremont St. Stockton 95205 <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#1 EXT. APN# / LAND USE APPLICATION# <br /> ( 209) 547-1700 L� 1�/� <br /> PHONE#Z EXT /� BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> Carrie Miller CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> Elite IV Contrcators 209 461-6337 <br /> HOME or MAILING ADDRESS FAX# <br /> 2535 Wigwam Dr. ( 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 law�s�.../l <br /> APPLICANT'S SIGNATURE: ��j)A�,p xda*Q/L DATE: 9/30/15 X <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT`ht Office Manager <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 <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. A <br /> TYPE OF SERVICE REQUESTED: LD Replacment(87) ix czi <br /> COMMENTS: 3 <br /> J �0 <br /> hFtiljO'�pU�O , <br /> ACCEPTED BY: rcl EMPLOYEE#: DATE: <br /> ASSIGNED TO: V6 EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): C� ��/i5 SERVICE CODE: jCr (�' P 1 E: Z J <br /> Fee Amount: C U�x Amount Pai 3�h O� Payment Date 30 !S <br /> Payment Type Invoice# Ch # //03 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />