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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # S VICE REQUEST # <br /> Gas Retail " " v l/ <br /> OWNER / OPERATOR <br /> CHECK ifBILLING ADDRESS ® <br /> Sandu Singh <br /> FACILITY NAME <br /> Country Mart Gas & Food <br /> SITE ADDRESS S Chrisman Road Tracy CA <br /> 34243 Street Number Direction Street Name ON Zi Code <br /> HOME Or MAILING ADDRESS ( If Different from Site Address) <br /> same as above Street Number Street Name <br /> CITY STATE zip <br /> PHONE #'1 EXT. APN # LAND USE APPLICATION # <br /> (209 ) 914 -5583 <br /> PHONE #2 EXT, BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> Deborah Jones CHECI< IfBILLING ADDRi % s <br /> BUSINESS NAME PHONE # EXT <br /> Elite IV Contractors ( 209) 461 om6337 <br /> HOME or MAILING ADDRESS FAX # <br /> . 2535 Wigwam Drive (9nm 461 -6342 <br /> CITYStockton C <br /> STATE ZIP95205 <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 : / �� .� DATE ; 2/08/2021 <br /> PROPERTY BUSINESS OWNER ❑ OPERATOR I 1 AGER ❑ OTHER AUTHORIZED AGENT ®.Administrative Assistant <br /> If APPLICANT is not the BILLING PARTY proofof 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 ass nt information <br /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the Same time I t lyj1$ Or <br /> my representative . ;r�777 l 0 , 7 <br /> TYPE OF SERVICE REQUESTED : J r{4t <br /> COMMENTS : 7 o2/s <br /> SA 'V JOA <br /> HEALT i� NMECO <br /> N � Y <br /> OEPAl7TnAL <br /> ACCEPTED BY : EMPLOYEE #: DATE; <br /> ASSIGNED TO : PLOYEE M DATE : <br /> Date Service Complete ( if already completed) : SERVICE CODE : e7F PIE: . <br /> Fee Amount : ` ir Amount Paid /S2 � � � Payment Date <br /> Payment Type Invoice # Check # S Received By; <br /> EHD 48-02-025 SR FORM (Golden Rod ) <br /> 07/17/08 <br />