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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # SERVICE REQUErE��ST # <br /> Gas & Food Retail Fk000 51 8 'q IS ?j b 01CD <br /> OWNER / OPERATOR <br /> Jarnail Ramboj CHECK If BILLINGADDRESSE] <br /> FACILITY NAME —/ / ► <br /> SITE ADDRESS I 14�T7 W Lathrop Road #9718 Lathrop 95330 <br /> Street Number Direction St eot Name Ci ZipCode <br /> HOME or MAILING ADDRESS (If Different from Site Address) Same A <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE #1 ExT. AP # LAND USE APPLICATION # <br /> ( 209 ) 858-2666 �� t� (� ``1 <br /> PHONE #2 ExT. BOS DISTRICT ® LOCATION CODE <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 /> CITY Stockton STATE CA ZIP 95205 <br /> BILLING ACKNOWLEDGEMENT : 1 , 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: 6/21 /2021 <br /> PROPERTY / BUSINESS OWNER ❑ OPERATOR / DAN GER ❑ OTHER AUTHORIZED AGENT ® Administrative Assistant <br /> If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required Title <br /> li 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 . p <br /> TYPE OF SERVICE REQUESTED : L ( kPF r4C ' vAII <br /> COMMENTS; o F ��� FO <br /> S 24? <br /> q <br /> N � 2� <br /> ht;q TYRO M� CO ?, <br /> nL O"P4RTgtN <br /> ACCEPTED BY: 'V EMPLOYEE #: DATE: 2 � <br /> ASSIGNED TO ; vvv „ Q St `� EMPLOYEE #: DATE :C � 2� <br /> Date Service Completed�( if-already compplleted ) : SERVICE CODE / 9 & Z el Q PIED <br /> 2 <br /> Fee Amount: ` .L�/L�'� � � Amount Pa 706, OD Payment Date Z <br /> Payment Type t Invoice # Check # /o z ecel d By ; <br /> EHD 48-02-025 SR FORM (Golden Rod) <br /> REVISED 11 /17/2003 <br /> jl <br />