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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# S VICE R�jEpUEST`# <br /> Gas Station/Food Facility <br /> OWNER/OPERATOR <br /> Chacko Thomas CHECK if BILLING ADDRESS <br /> FACILITY NAME <br /> Emil's Liquors/Chevron(Kdspy Krunchy Chicken) <br /> SITE ADDRESS <br /> 1405 California St. Escalon 95320 <br /> Street Number Direction Street Name city zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) /t,i Imo_/ P -e <br /> 140q Street Number Street Name / <br /> CITY �CC fL_(I-^` STATE ^ ZIP 9S3 %/^ <br /> v <br /> PHONE#1 En. APN# LAND USE APPLICATION# <br /> ( log) ` r9 - z 93 <br /> PHONE#2 En. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR — <br /> KelebFachner Gk� 'fg� CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# Exr' <br /> CKS,Inc. 209 3257431 <br /> HOME or MAILING ADDRESS FAx# <br /> PO Box 820 ( 209 ) 370-8395 <br /> CITY Lodi STATE CA ZIP 95241 <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: /1CL(�QD /G �GLC/GyLQ41 DATE- 11/6/2020 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT© Contractor. CKS, Inc. VP <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 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: A-.1d j'r7D�p.� rOQpl "LU yw-c_we- CLcCcC <br /> COMMENTS: N"i <br /> �tctw�tdL S�t� j� ja ( RECEs EEL.' <br /> NOV 10 2026' <br /> SAN JOAQUIN COUN i r <br /> ACCEPTED BY: 6CA_ 'fyK CS c-D EMPLOYEE#: HEALTH EDMATMEkT_/_ <br /> ASSIGNED TO: FcAh� EMPLOYEE#: DATE: t f— <br /> Date Service Completed (if airs dy completed): SERVICE CODE: 5- 2-3 PIE: iito p <br /> il <br /> Fee Amount: 45-6. — Amount Paid �C"(�6 Payment Date <br /> Payment Type ( N Invoice# n LCheck# Received By: <br /> EHD 48-02-025 ✓°' "1 t 6 S S 9q v SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />