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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # SERVICE REQUEST # <br /> oo 2 � Sit r) j �� <br /> OWNER / OPERATOR Jay ArdaSS <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME Western Food And Fuel <br /> SITE ADDRESS 3032 Waterloo Rd <br /> Stockton 95205 <br /> Street Number Direction Street Name Ci Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE #1 Eve APN # LAND USE APPLICATION # <br /> ( 206 346 -9232 <br /> PHONE #2 EXT• BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR CHECK if BILLING ADDRESS ® <br /> Megan Mitchell <br /> BUSINESS NAME PHONE # EXT. <br /> Elite IV Contractors _ <br /> 337 <br /> HOME or MAILING ADDRESS FAX # <br /> 2535 Wigwam Dr ( 200 461w6349 <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 or <br /> activity will be billed to me or my business as identified on this form . �' - <br /> also certify that I have prepared this application and that the ork to be erformed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards, STATE and FEDERAKlla � <br /> APPLICANT' S SIGNATURE : Z L- DATE : <br /> PROPERTY / BUSINESS OWNER ❑ OBATOR / MANAGER ❑ OTHER AUTHORIZED AGENT IR Office Assistant <br /> If APPLICANT is nota BILLING 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 environmental/site assessment information <br /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it IS available and at the same time It is provided t0 me or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED : u S RECelix <br /> COMMENTS: <br /> OCT 0 6 2020 <br /> SAN JOAQUIN <br /> EN <br /> HEALTH DEAR AL TY <br /> ACCEPTED BY: JJ EMPLOYEE #: DATE : <br /> 10 <br /> 0 <br /> ASSIGNED TO : L EMPLOYEE #: DATE: !d Z V <br /> Date Service Completed (if a ready completed) : SERVICE CODE: P I E : L <br /> Fee Amount : O!J Amount Pal L f S� �� Payment Date �b oZ D <br /> Payment Type ��6— Invoice # Check # l 1 ecei ed By : <br /> EHD 48-02-025 SR FORM (Golden Rod ) <br /> 07/17/08 <br />