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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # SERVICE REQUEST�] <br /> # <br /> OWNER / OPERATOR Gurvinder Singh CHECK If BILLING ADDRESS ❑ <br /> FACILITY NAME North Pole Gas & Food <br /> SITE ADDRESS 574 N Grant Line RD Tracy 95376 <br /> Street Numbor Direction I Street Name Citv ZipCode <br /> HOME or MAILING ADDRESS (If Different from Site Address) PAY ENT <br /> Street Number Street Name <br /> CITY STATE ZIP ED <br /> EEEEWIII� go <br /> PHONE #1 EXT. APN # LAND USE APPLICATION # JUL2020 <br /> ( 209 833-3416 SAN <br /> PHONE #2 EXT BOSDISTRICT "A" <br /> TE� E OAS Ty <br /> ( ) MENT <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR Megan Mitchell CHECK if BILLING ADDRESS ® <br /> PHONE # . ExT• <br /> BUSINESS NAME Elite IV Contractors ( 909 461m6337 <br /> HOME or MAILING ADDRESS FAX # <br /> 2535 Wigwam Dr ( 20q 461 �6342 <br /> CITY Stockton STATE ZIP <br /> 95376 <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 a work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards, T E and/FEDERAL laws . rte, <br /> APPLICANT'S SIGNATURE � j DATE : �U � ( J � <br /> PROPERTY / BUSINESS OWNER ❑ 9 ERATOR / MANAGER OTHER AUTHORIZED AGENT Office Assistant <br /> if APPLICANT is not th .LUNG 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 /> t0 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. 7 <br /> TYPE OF SERVICE REQUESTED : r �c / t. <br /> COMMENTS : <br /> ACCEPTED BY: V �a I VL7 EMPLOYEE M DATE: <br /> G / 001 <br /> EMPLOYEE #: DATE: 7 �� <br /> ASSIGNED TO : _ 1 (i L�-C �(• / <br /> Date Service Completed (if already completed) : SERVICE CODE: P I E: " <br /> Fee Amount 2 <br /> 170 Amount Paid / S� w Payment Date $ ZD <br /> Payment Type I Invoice # Check # / Received By : <br /> EHD 48-02-025 SR FORM (Golden Rod) <br /> 07/17/08 <br />