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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # SERRV�VIIC^^E REQQUUEST # <br /> Gas & Food Retail at%t Qui J 0 ; <br /> OWNER / OPERATOR <br /> Quik Stop Markets #39 CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> Quik Stop Markets #39 <br /> SITE ADDRESS 2285 E Fremont Street Stockton 95205 <br /> Street Number Direction Street Name M city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 302 E Third Street, Suite 300 <br /> Street Number Street Name <br /> CITY <br /> Cincinnati STATEOH <br /> Zip45202 <br /> PHONE #1 ExT• APN # LAND USE APPLICATION # <br /> ( 209 ) 464- 1038 ILAi AA <br /> PHONE #2 Exr. BOS DIS,TRICZ 1 , LOCATION GQD <br /> ( ) V ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR CHECK If BILLING ADDRESS <br /> Deborah Jones , Administrative Assistant <br /> BUSINESS NAME PHONE # En' <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: 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: 4/27/2021 <br /> PROPERTY / BUSINESS OWNER ❑ OPERATO / 1ANAGER ❑ OTHERAUTHORIZED AGENT El 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 Axpiat the same time it is <br /> provided to me or my representative . ^1 <br /> TYPE OF SERVICE REQUESTED : S �./7V At A <br /> COMMENTS : <br /> sqN J 03 2 <br /> yFq�TyRoti�N co �21 <br /> oFpgR 44 y <br /> ACCEPTED BY: 0 EMPLOYEE M DATE : 6 Lv <br /> ASSIGNED TO: ` V vO EMPLOYEE #: DATE* <br /> 13 '. Z/ <br /> Date Service Completed ( if already completed) : � SERVICE CODE. PIE 62& <br /> Fee Amount: OO Amount Pai 6 Q � Paymff ent Date c3 1 <br /> Payment Type Invoice # Check # Received By : <br /> dtu <br /> EHD 48-02-025 SR FORM (Golden Rod) <br /> REVISED 11 /17/2003 <br />