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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQ EST# <br /> b� -2 <br /> Gas & Food Retail � � ' � <br /> OWNER/OPERATOR <br /> Ru index Pada CHECK IfBILLING ADDRESS <br /> FACILITY NAME Arco am/pm <br /> _=SREADDRESS 14931: N Flag-City Blvd Lodi 95242 <br /> • Street Number Oilaction Street Name city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> -same as above street Number '$ .e'- <br /> CITY STATE ZIP <br /> PHONE#1 Exr'_ APN# LAND USE APPLICATION# <br /> ( 1 <br /> PHONE#2 Exr• BOS DISTRICT LOCATION CODE <br /> ( 1 <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> Deborah Jones CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# Exr. <br /> Elite IV Contractors 209 461-6337 <br /> HOME Or MAILING ADDRESS FAX# <br /> 2535 Wigwam Drive ( ) 461-6342 <br /> CITY STATE srATE CA zJP 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 ENwRoNMENTAL 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,Slandards,STATE and FEDERAL.laws. <br /> APPLICANT'S SIGNATURE: n DATE: 3/24/2021 <br /> PRO PERTY/BusiNEssOu'NER❑ OPERAT R/ AGER ❑ OTHER AUTHORTZEDAGEYTM Administrative Assistant <br /> If APPLICANT 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 environuTental/site assessment <br /> infonDation to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: US 7— /�1� <br /> e/n2y", <br /> COMMENTS: <br /> ACCEPTED BY: --�r /V EMPLOYEE#: DATE: �y/2 <br /> ASSIGNED TO: C/( Ca r/ EMPLOYEE#: DATE: <br /> Date Service Completed (if already Completed): :0 2 SERVICE CODE: qyJPIE: <br /> TL <br /> Z% <br /> 23 <br /> Fee Amount:-0/02 00 Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> E H D 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />