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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # SERVICE REQUEST # <br /> Gas & Food Retail- <br /> S �V g3 �� <br /> OWNER / OPERATOR <br /> Quik toMarkets # 120 CHECK if BILLING ADDRESS CI <br /> FACILITY NAME <br /> Quik Stop Markets #120 <br /> SITE ADDRESS 9321 Thornton Road Stockton 95209 <br /> Street Number Direction Street Name City Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 302 W Third Street Suite 300 <br /> Street Number Street Namp <br /> CITY Cincinnati STATE OH Zip 45202 <br /> PHONE #i ExT. APN # LAND USE APPLICATION # <br /> ( 209 ) 478-7149 <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 209 461 =6337 <br /> HOME Or MAILING ADDRESS FAX # <br /> 2535 Wigwam Drive ( 209 ) 461 -6342 <br /> CITY Stockton CA STATE Zip 95206 <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 : <br /> 4 /22/2021 <br /> PROPERTY / BUSINESS OWNER❑ OPERATORANAGER ❑ OTHER AUTHORIZED AGENT ® Administrative Assistant <br /> If APPLICANT is not the BILLING PART ,Yproof 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 environmental/site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available end at the same time it is <br /> provided to me or my representative . P <br /> TYPE OF SERVICE REQUESTED : <br /> COMMENTS : A pR <br /> SAN JO 221 <br /> EN <br /> VIRpDIN ro CpUNTY <br /> HEpLTh DE ARTTgL <br /> MENT <br /> ACCEPTED BY: EMPLOYEE M DATE : <br /> ASSIGNED T0 : EMPLOYEE #: DATE . <br /> Date Service Completed (if already completed) : SERVICE CODE: PIE: 7y/ ��' <br /> Fee Amount: t? a Amount Pai Payment Date 2/ ✓ �! <br /> Payment Type Invoice # Check # 2�3 � b� Receiv d By : AIR I <br /> FHn 4R-09.095 SR FORM (Golden Rod) <br />