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Violation # 214 / QS # 120 SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID # SERVICE REQUEST # Gas & Food Retail SiQON � I (FV OWNER / OPERATOR Qulk Sto Markets # 120 CHECK If BILLING ADDRESSO FACILITY NAME Quik Stop Markets # 120 SITEADDRESS 9321 Thornton Road Stockton 95209 Street Number Direction Street Name city Zip Code HOME or MAILING ADDRESS (If Different from Site Address) 165 Flanders Road Street Number Street Name CITY Westborough STATE MA ZIP 01581 PHONE #1 EXT. APN # LAND USE APPLICATION # ( 209 ) 478-7149 PHONE #2 EXT• BOS DISTRICT LOCATION CODE ( ) CONTRACTOR / SERVICE REQUESTOR REQUESTOR Deborah Jones CHECK If BILLING ADDRESS BUSINESS NAME PHONE # EXT. Elite IV Contractors 209 461 -6337 HOME or MAILING ADDRESS FAX # 2535 Wigwam Drive ( 209 ) 461 -6342 CIN Stockton CA STATE Zip 95205 BILLING ACKNOWLEDGEMENT: I , the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as identified on this form . 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 COUNTY Ordinance Codes, Standards, STATE and FEDERAL laws. APPLICANT ' S SIGNATURE : 14 a DATE : 5/21 /2021 PROPERTY / BUSINESS OwNER ❑ OPERAT R / 1ANAGER ❑ OTHER AUTHORIZED AGENT ® Administrative Assistant If APPLICANT is not the BILLING ARTY, proof of authorization to sign is required Title AUTHORIZATION TO RELEASE INFORMATION : When applicable, 1 , the owner or operator of the property located at the above site address , hereby authorize the release of any and all results , geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at th fjSiTte time it is provided to me or my representative. DDD IV TYPE OF SERVICE REQUESTED : srgy.,L2fif COMMENTS: MAY SA 6 ee �� HF Nv RQt//N ?011 J) Dlll cryoOPMENouNT MFNr, ACCEPTED BY: Ta 1V /U EMPLOYEE #: DATE ASSIGNED TO � C / f (N�( ��Q �� EMPLOYEE #: DATE: Date Service Completed ( if already completed) : ICE CODE@/ q 2 p P I E: 1r ..�� Fee Amount: ��. 0 CIL' y�jr� Amount Paid � � Payment ate U �� Payment Type � �r Invoice # Check # ' 7 d Receive By . EHD 48-02-025 SR FORM (Golden Rod) REVISED 11 /17/2003 Fir- t, A..e_ 4�o 0 Wa4 0 a PUrrl.it t pw"