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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 Retail rwoz / Ls �J C'R00Uq7 I <br /> OWNER / OPERATOR <br /> Interstate A Enterprises , Inc / City Food & Liquor <br /> CHECK If81LLINGADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS 16470 Cambridge Drive Lathrop 95330 <br /> Street Number Direction I Street Name city Zip 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 Exr• APN # LAND USE APPLICATION # <br /> ( 209 ) 6474273 <br /> PHONE #2 ExT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR rVI <br /> Deborah Jones CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE # ExT' <br /> 2535 Wigwam Drive Stockton , CA 95205 209 461 -6337 <br /> HOME or MAILING ADDRESS FAX # <br /> same as above ( 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 <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 ; 10/20/2021 <br /> i <br /> PROPERTY / BUSINESS OWNER ❑ OPERATOR ANAGER ❑ OTHER AUTIIORIZEDAGENT ® Administrative Assistant <br /> IfAPPLICANT is not the BILLING PARTY, proof of authorization to sign is required Title j <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 and at the same time it is <br /> j <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: RECEI D <br /> COMMENTS : NOV 17 2021 <br /> D VM <br /> SAN JOAQUIN COUNTY <br /> ENUIRONMEN rAL <br /> HEALTH 13PARI MEN, <br /> ACCEPTED BY: / EMPLOYEE #: DATE: f �f <br /> V <br /> ASSIGNED TO : EMPLOYEE #: DATE: bqz <br /> Date Service Completed (If already completed) : SERVICE CODE: � CJ2Gf P / E: e5og <br /> Fee Amount: L f CJ` j " `' Amount Paid — Payment Date ZU L ) <br /> Payment Type Invoice # TE ;W# ' 3 � 3 (P Received By : <br /> I <br /> EHD 4&02-025 ! SR FORM (Golden Rod) <br /> REVISED 11 /17/2003 <br />