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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # ScOVICE REQUEST # <br /> Gas & Food Retail � ��� �� <br /> OWNER / OPERATOR <br /> CHECK if BILLING ADDRESS ❑ <br /> Mr. Singh <br /> FACILITY NAME <br /> Jahant Food & Fuel Sto Inc . <br /> SITEADDRESS 24323 E Highway 99 Acampo 95220 <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 Exr. APN # LAND USE APPLICATION # <br /> ( 209 ) 327 -2836 <br /> PHONE #2 ExT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR CHECK if BILLING ADDRESS ® <br /> Deborah Jones <br /> BUSINESS NAME PHONE # ExT. <br /> Elie IV Contractors 209 461 -6337 <br /> HOME or MAILING ADDRESS FAX # <br /> ( 209 ) 461 -6342 aaaa <br /> CITY TATE ZIP <br /> Stockton 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 ENvIRONMSNTAL 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 : Q DATE : 3/ 18/2021 <br /> PROPERTY / BUSINESS OWNER 13 OPERATOR / VUAGER ❑ OTHER AUTnORIZEDAGENT ® "aaAdministrative Assistant <br /> If APPLICANT is nol 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 . P4 Vaq <br /> TYPE OF SERVICE REQUESTED : C C <br /> oe WOO <br /> COMMENTS: APR ' <br /> SqN Jo4 4 ?021 <br /> l ENVq Qt)/A/ C <br /> l` yFALTy pMFNp ANT y <br /> ART MINT <br /> ACCEPTED BY: d / LJ� iL EMPLOYEE #: DATE: <br /> ASSIGNED TO: Lt&tfa <br /> Fr" 'AQ EMPLOYEE M. DATE: G� 3 moi! <br /> Date Service Completed (if already completed) : SERVICE CODE: P / E: d;L 7D0 <br /> Fee Amount:' Amount Paid �S� ZX� Payment Date v <br /> Payment Type Invoice # Check # 12.23 ;2�pcf. Received By : <br /> EHD 48-02-025 SR FORM (Golden Rod ) <br /> REVISED 11 /17/2003 <br />