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SAN JOAQIJIN COUNTY E. NVIRONMENTAL WEALTi-i DEPARTMENT <br /> GiERVICE REQUEST _ <br /> Type of Business or Property FACILITY ID II SERVICE REQUEST # <br /> Gas Station F'q (goo,o, 40���� <br /> OWNER / OPERATOR <br /> Swaran Chouhan CHECI< ifBILLING ADDRESS <br /> FACILITY NAME GSG Gas & Mart <br /> � , L L <br /> SITE ADDRESS 701 E 701 E , CharterWay— Stockton 95206 <br /> Street Number Direction I Street Name City Zip Code <br /> HOME or MAILING ADDRESSN/A ( If Different from Site Address) <br /> Street Numbor Street Name <br /> CITY STATE ZIP <br /> PHONE #1 ExT• APN # LAND USE APPLICATION # <br /> ( 209 ) 993- 1298 <br /> PHONE #2 Exr. BOS DISTRICT LOCATION CODE <br /> ( 209 ) 467-0305 <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR CHECK if BILLING ADDRESS® <br /> Carrie Miller <br /> BUSINESS NAME Elite IV Contractors PHONE # Exr. <br /> 209 461 -6337 <br /> HOME or MAILING ADDRESS FAX # <br /> 2535 Wigwam Dr ( 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 or <br /> activity will be billed to me or my business as identified on this form , <br /> also certify that I have prepared this pli ation and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards, TAT and FEDERAL la IA , <br /> APPLICANT' S SIGNATURE : ` 1 W� DATE : 6/ 18/2021 <br /> PROPERTY I BUSINESS OWNER ❑ OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT ® Office Manager <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 above <br /> site address , hereby authorize the release of any and all results , geotechnical data and/or environmental/site assessment information <br /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same tiny is provided to me or <br /> my representative . e / ,- Y <br /> TYPE OF SERVICE REQUESTED : �'� C CEF� <br /> COl,1MENTS : t <br /> JUN 2 ' 2021 <br /> SAIvjo <br /> FIE N R0NMECOUNTy <br /> LTH pEpq RTTAL <br /> ACCEPTED BY : 't'�] ' EMPLOYEE #: DATE : � j <br /> ASSIGNED TO : / vl f \ EMPLOYEE #: DATE: r <br /> Date Service Completed ( if already completed ) : SERVICE CODE : lq(f Z 2`f f P I E : � <br /> Fee Amount: ( Amount Pai L�S vo Payment Date <br /> 1211 <br /> Payment Type Invoice # Check # �� ` 3 242 Received By : <br /> EHD 48-02-025 SR FORM ( Golden Rod ) <br /> 07/ 17/08 <br />