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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 LqI5 Rot ;7 3; <br /> OWNER / OPERATOR <br /> Mr . Que CHECK If BILLING ADDRESS ® <br /> FACILITY NAME <br /> Flag City Chevron <br /> SITE ADDRESS 6421 Capitol Avenue Lodi 95242 <br /> Street Number Direction 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 ExT. APN # LAND USE APPLICATION # <br /> ( 209 ) 334 - 0975 <br /> PHONE #Z EXTs BOS DISTRICT LOCATION CODE <br /> ( ) <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 /> c 'n"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 : 5/ 13/2021 <br /> PROPERTY / BUSINESSOwNER ❑ OPERATOR / U, NAGER ❑ OTHER AUTHORIZED AGENT ® Administrative 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 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 /> provided to me or my representative . ,(� <br /> TYPE OF SERVICE REQUESTED : ITC <br /> COMMENTS: �q M4Y < <br /> At do <br /> iyF Ro <br /> �y0 pq�T0�NT <br /> M <br /> ACCEPTED BY : G EMPLOYEE #: DATE : ZU � <br /> ASSIGNED TO : C / EMPLOYEE # : DATE : /y� �WO� <br /> Date Service Completed ( if already completed) : SERVICE CODE, P 1 E : .C) <br /> Fee Amount: e? 00 Amount Pal Payment Date Y Z <br /> Payment Type ' _ Invoice # Check # 1251 Recefived By : <br /> EHD 48-02-025 SR FORM (Golden Rod) <br /> REVISED 11 /17/2003 <br />