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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITYID # SERVICE REQUEST # <br /> Gas & Food Retail 00U `y 1? S� Q6 rVaQ �(QoLf <br /> OWNER / OPERATOR <br /> Quik Stop Markets # 121 CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> Quik Stop Markets # 121 <br /> SITEADDRESS 1196 W Louise Ave Manteca 95336 <br /> Street Number Direction I Street Name c1tv Zin Code <br /> HOME or MAILING ADDRESS ( If Different from Site Address) 802 W Third Street <br /> 302 W Third St Ste 300 street Number street Name <br /> CITYSTATE <br /> OHE zip <br /> 45202 <br /> PHONE #1 EXT* APN # LAND USE APPLICATION # <br /> ( 209 ) 239-2957 <br /> PHONE #2 ExT. BOS DISTRICT """] LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> Deborah Jones CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE # EXT. <br /> Elite IV Contractors 209 641 -6337 <br /> HOME or MAILING ADDRESS FAX # <br /> 2535 Wigwam Drive ( 209 ) 641 -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 <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 : DATE . q <br /> PROPERTY / BUSINESS ONNF,R ❑ OPERATOR / NAGER ❑ O'1'l1ERAU'1'110RIZEDAGENT10Administrative Assistant <br /> IfAPPLICANT 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 environm ntal/site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and me time it is <br /> provided to me or my representative. / M <br /> TYPE OF SERVICE REQUESTED: S / <br /> ( npj� <br /> COMMENTS : Z <br /> SqN 20 <br /> f y�q TyRO MN CO 2� <br /> ACCEPTED BY : /f �� EMPLOYEE # : DATE: Z Z <br /> ASSIGNED T0 : �/Y EMPLOYEE M DATE: 3 <br /> Date Service Completed (if already completed) : _ SERVICECoDE : <br /> Fee Amount: ZYLam'' Amount PaidLl�/ , Payment Date <br /> Payment Type 51j � Invoice # Check [#/ Z � �S Received y : <br /> EHD 48-02-025 SR FORM (Golden Rod ) <br /> REVISED 11 /17/2003 <br />