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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # SERVICE REQUEST # <br /> Qoo® g � Q co6c) SS (a <br /> OWNER / OPERATOR <br /> QUe CHECI< If BILLING ADDRESS <br /> FACILITY NAME <br /> Flag City Chevron <br /> SITE ADDRESS 6424 Capitol Ave Lodi 95242 <br /> Street Number Direction Street Name Citv Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE #1 EXT APN # LAND USE APPLICATION # <br /> ( 209 ) 334-0975 <br /> PHONE #2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> Megan Mitchell CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE # EXT . <br /> Elite IV Contractors 209 461 -6337 <br /> HOME or MAILING ADDRESS FAX # <br /> 2535 Wigwam Dr <br /> ( 209 ) 461 -6342 <br /> CIN 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 /> 1 also certify that I have prepared this application and that Uhl work (be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards, ST FE ERAL I ws. <br /> APPLICANT' S SIGNATURE : , ��� _ DATE : ( f � � �) <br /> PROPERTY / BUSINESS OWNER ❑ OPERAT R / ANAGER THER AUTHORIZED AGENT ® Office Assistant <br /> If APPLICANT is not the BILLING AR proof of authoriza ion to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMA 10: 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 to me Or <br /> my representative . <br /> TYPE OF SERVICE REQUESTED : 1 (41)7\ ( �14W <br /> COMMENTS : <br /> I AY � � 2019 <br /> N ALTw NUIl <br /> V/RoIV �1JN IY <br /> Al <br /> ACCEPTED BY : ' EMPLOYEE #: '4176% W7 <br /> ASSIGNED TO : � � EMPLOYEE M DATE: <br /> Date Service Completed (if already Completed) : SERVICE CODE : PIE: <br /> Fee Amount: Amount PaidPayment Date <br /> 1 <br /> Payment Type % S " <br /> l�� Invoice # Check # Received By : <br /> EHD 48-02-025n SR FORM ( Golden Rod) <br /> 07/17/08 `7 0 '7 & 9e 7 K � <br />