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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 Retail00 <br /> OWNER / OPERATOR TX <br /> Quik Stop Markets # 125 0 000 aC CHECK IfBILLING ADDRESS <br /> � <br /> FACILITY NAME <br /> Quik Stop #125 <br /> SITEADDRESS 1580 W Main Street Ripon 95366 <br /> SlreetNumber Dlrectlon I Street Name City Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 302 W Third Street <br /> 302 W Third St Ste 300 Street Number Street Name <br /> CITY STATE ZIP <br /> Cincinnati OH 45202 <br /> PHONE #1 ExT• APN # LAND USE APPLICATION # <br /> ( 209 ) 5994261 <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 209 641 -6337 <br /> HOME or MAILING ADDRESS FAX # <br /> 2535 Wigwam Drive ( 209 ) 641 -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: 1l f i2W I <br /> PIt01'ERTY / BusINESSOWNER ❑ OPERATOR ANAGER ❑ OTHER AUTHORIZED AGENT ® Administrative Assistant <br /> If APPLICANT is not the BILLING PAR77, proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION : When applicable, 1 , 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 : �. 1E R6 /r627p/ REF <br /> COMMENTS: APR z <br /> ,SAN Joq 20z1 <br /> H�ENVI 4NM C � Y <br /> ALTH pEPARTT�NT <br /> ACCEPTED BY: EMPLOYEE #: DATE: , <br /> ASSIGNED TO : ' 1 EMPLOYEE #: DATE : <br /> Date Service Completed ( if already completed) : SERVICE CODE : q , P I E ; Doe <br /> Fee Amount: G�/ „ pZ, Amount Pal Payment Date <br /> Payment Type ' SInvoice # Check # l 2 DS 2yAP Receive By : <br /> EHD 48-02-025 SR FORM (Golden Rod) <br /> REVISED 11 /17/2003 <br />