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0 q RECEIVED <br /> DEC 15 2015 <br /> ` SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE .REQUEST ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Gas Station �� � Gb-- �G <br /> OWNER/OPERATOR O <br /> Rupi and Bill CHECK ifBIMMOADDRESSC] <br /> FAcIurY NAME Flames Liquor <br /> SITE ADDRESS <br /> 1301 111 o N ber Kettlernen Lane E:Lodi 95240 <br /> S et Name t <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> CITY <br /> Num r eet N me <br /> STATE zip <br /> PHONE#1 Ext. APN* <br /> (209 ) 334-3233 LAND USE APPLICATI6N <br /> ©��6 tr��ja�� <br /> RNONE#2 EXT, <br /> SOS DISTRICT( I LocAnOto CODE <br /> C)o <br /> CONTRACTOR SERVICE REQUESTUR <br /> REQUESTOR Carrie Miller <br /> CHECK if_ oADDR�gs[3 <br /> BUSINESS NAME <br /> Elite N Contractors PH209 461-6337 <br /> Ext <br /> HoME or MAILING ADDRESS ( 2 <br /> 2535 Wigwam Dr AX# 461-6342 <br /> CITY Stockton STAB ( 2091 CA Zip 95205 <br /> BILLING ACK]VOWLEDGEME-J: 1, the undersigned property or business owner,operator or authorized agent of same. <br /> acknowledge that all site and/or project specific ENVIRONMENTAL,HF.At_TH 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 T have prepared this application and that the work to be perforated will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, TATE and FEDERAL <br /> APPLICANT'S SIGNATURE: DAi,E: 12/15/15 <br /> PROPERTY/BUsiNzss OWNER© OPERAroit/RIANAGER ❑ OTHER AUTHORIZED AGEII*r Office Manager <br /> lf.4PPL/CA,4'T is not then_L.A-G P�IREK proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE 11NF0Rlt'I,&T ON: 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. <br /> TYPE OF SERVICE REQUESTED: 87 LD Replaced R 'IFN <br /> COMMENTS: FQ <br /> ®Eels c <br /> �.VfyyOgQU�,y �O�J <br /> ACCEPTED BY: C-) EMPLOYEE#: DATE: Z <br /> / <br /> ASSIGNED TO: EMPLOYEE#: DATE: / Z <br /> Date Service Completed (if already completed): 12/14/15 SERVICE CODE: Cj Sr PIE: 8 <br /> Fee Amount: lf>b Amount Pa <br /> .3q0.Dl7payment Date /•t/ /S <br /> Payment Type eL Invoice# C # S/,S / Received By: <br /> EHD SR FORM(Golden Rod) <br /> REVISEDSED 11 11/11 7/2003 <br />