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SAN JOAN COUNTY ENVIRONMENTAL HEAL DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Gas Station 2A 667� 3 <br /> OWNER/OPERATOR <br /> Quik Stop Markets Inc CHECK if BILLING ADDRESS <br /> FACILITY NAME Quik Stop 138 <br /> SITE ADDRESS 1153 Lincoln Blvd Tracy 95376 <br /> Street Number I Direction I StreetName city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 4567 Enterprise Street <br /> Street Number Street Name <br /> CITY Fremont STATE Ca Z'P 95376 <br /> PHONE#f EXT• APN# LAND USE APPLICATION# <br /> ( 800) 972-0982 2 Z <br /> PHONE#Z EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> Megan Mitchell CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# E <br /> m. <br /> Elite IV Contractors 209 461-6337 <br /> HOME or MAILING ADDRESS 2535 Wigwam Dr FAx# <br /> ( 2094461-6342 <br /> CITY Stockton STATE Ca Z'P 95205 <br /> BILLING ACKNOWLEDGEMENT: 1, 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 laws. <br /> APPLICANT'S SIGNATURE: Afewi MftcheU DATE: 10/27/2017 <br /> PROPERTY/BUSINESS OWNER 13 OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT 121 Office Assistant <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. <br /> TYPE OF SERVICE REQUESTED: ku AYA4�NT <br /> COMMENTS: <br /> ocr �a®x ri.:att�s_ .w <br /> 02017 <br /> E��R°��rNEti=�,ti� 0C� 3 0 2017 <br /> nA TTH At <br /> IS <br /> ACCEPTED BY: /.�1 EMPLOYEE#: 2,4�f0 DAT if; 17 :,r, r <br /> ASSIGNED TO: Poe tN R. <br /> EMPLOYEE#: ' DATE: <br /> Date Service Complete If already completed): SERVICE CODE: I P I E: v <br /> Fee Amount: S� Amount Paid �&- Payment Date /v 3b <br /> Payment Type �.5� Invoice# Che # 3/7,2 Re' d By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />