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SAN JOAQ0 COUNTY ENVIRONMENTAL HEALTHRARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Gas& Food Store <br /> A DI�e -,�L, �.CO-7a1 01 <br /> OWNER I OPERATOR <br /> CHECK if BILLING ADDRESS <br /> Ruppie Padda <br /> FAciuTY NAME Falmes <br /> SITE ADDRESS 1301 1. W. Kettleman Lane Lodi pp <br /> Street Number Dkectlm Street Name CKV '! <br /> HOME or MAILING ADDRESS (if Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#9 EXT. APN# , j LAND USE APPLK:ATION# <br /> `7 <br /> ( 200 914-8735 v 3 b d <br /> PHONE#2 EXT. SOS DISTRICT' LOCAT <br /> gION CODE <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK 1f BILLING ADDRESS <br /> Kim White <br /> BUSINESS NAME PHONE# °R• <br /> Elite IV Contractors 209 461-6337 <br /> HOME or MAILING ADDRESS FAX# <br /> 2535 Wigwam Drive ( 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 ENvLRONMENTAL 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,STA1T and FEDERAL.laws. <br /> APPLICANT'S SIGNATURE: 6('(n 'Ikl DATE: <br /> p 5-13-2015 <br /> PROPERTY/$USINESSOWNER❑ OPERATOR I MANAGER 13 OTHER AUTHoRIzmAGENT[33epresentaive <br /> ff_4PPLICANT is not the Btt,LyG 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 environmentallsite 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. sicT <br /> TYPE OF SERMCE REQUESTED: Replace 91/131esel annular sensor&87 STP relay J%J1ED <br /> COMMENTS: A 2T 15 <br /> MA`( 1 `t <br /> O <br /> SAN 3AOUIN COUN <br /> ENV IROMENTAL <br /> HEALTH DEPAFtfME <br /> ACCEPTED BY: (16 I rA EMPLOYEE#: DATE: <br /> ASSIGNED TO: N/ <br /> EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: ,(� PIE: <br /> Fee Amount: Q Amount Paid �3 [v � (� Payment Date S I cf 'S <br /> Payment Type V ISA— I Invoice# Check# Received By: <br /> E H D 48-02-025 O oldela R <br /> REVISED 11/17/2003 <br /> MAY 14 20` <br />