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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> 43F VICE IEQUFST <br /> Type of Business or Property FACILITY ID # PERVICE REQUEST # <br /> Gas Retail ly gool9Cf <br /> OWNER / OPERATOR ``fes' UHECK It BILLING ADDRESS I " <br /> Avinash Singh <br /> FACILITY NAME <br /> Ranhawa Petro earn dba : EI Dorado Gas & Food Mart <br /> SITE ADDRESS 1901 SEI Dorado Street Stockton 95206 <br /> Street Number Direction Street Name City Zip Code <br /> HOME Or MAILING ADDRESS ( If Different from Site Address) SAME <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE #1 EXT, APN # LAND USE APPLICATION # <br /> ( 209) 451 -4632 <br /> PHONE #2 EXT. BOS DISTRICT LOCATION CODE <br /> ( 510) 557 -4508 <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR CHECK if BILLING ADDRESS 0 <br /> Deborah Jones <br /> BUSINESS NAME PHONE # EXT' <br /> Elite IV Contractors ( 209) <br /> 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 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 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 : -fcU� ' L " DATE : 12/01 /2020 <br /> PROPERTY / BUSINESS OWNER ❑ OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT ❑x 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 above <br /> site address , hereby authorize the release of any and all results , geotechnical data and/or environmental/site assessment information <br /> to 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 . <br /> TYPE OF SERVICE REQUESTED : <br /> COMMENTS : <br /> DEC 0 9 2020 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: 31Mw �� EMPLOYEE # : DATE : 2 / <br /> ASSIGNED TO : 11/ j( / <br /> EMPLOYEE # : DATE : Z� <br /> Date Service Completed leted ( if already completed) : SERVICE CODE : ' {% P 1 E: <br /> Fee Amount: ! Amount Paid LI 5- 6 Payment Date / 2 9 ?p <br /> Payment Type GepJ;f V► c Invoice # Check # 117 q 17 9 .r. <br /> (� Received By : <br /> EHD 48-02-025 SR FORM (Golden Rod ) <br /> 07/ 17/08 <br />