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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 Retail W GQ <br /> OWNER 1 OPERATOR <br /> Quik Stop Markets , Inc . CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> Quik Stop Markets , # 124 <br /> SITE ADDRESS 505 N Main Street Manteca 95336 <br /> Street Number Direction I Street Name city Zin Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 165 Flanders Road <br /> Street Number Street Name <br /> CITY Westborough STATE MA Zip 01581 <br /> PHONE #1 ExT• APN # LAND USE APPLICATION # <br /> ( 508 ) 270- 1400 4469 2 90 — 2lO 21 <br /> PHONE #2 ExT. BOS DISTRICT � .1 LOCATION CODE <br /> ( ) 0Cos <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> Deborah Jones CHECK If BILLING ADDRESS 0 <br /> BUSINESS NAME PHONE # Eut <br /> Elite IV Contractors 209 461 -6337 <br /> HOME or MAILING ADDRESS FAx # <br /> 2535 Wigwam Drive CA 95205 ( 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 & UCW DATE: 05/07/2021 <br /> PItoPERTY / BUSINESS OWNER ❑ OPERATC / TANAGER ❑ OTHER AUTHORIZED AGENT ® AdI111r11StratlVe ASSIStarlt <br /> ]f APPLICANT is not the BILLINGIP'A ' 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 . <br /> TYPE OF SERVICE REQUESTED : u S R <br /> COMMENTS ; VP <br /> AM Y 10 <br /> CD <br /> SA /V '10 20?1 <br /> hEq�Ty oRpAFNo ANT y i <br /> ACCEPTED BY: / N EMPLOYEE #: DATE: 1 T <br /> ASSIGNED TO : N (� EMPLOYEE #: DATE:OAS <br /> r J I Q <br /> Date Service Completed (if already completed) : SERMCE CODE: i G� PIE: <br /> 2 )D g <br /> Fee Amount: 4 7)�� Amount Pai � � Payment Date sZ /QLZZ <br /> Payment Type , Invoice # Check # 12 <br /> 0/ l0Y3 3 Received By : <br /> EHD 48-02-025 SR FORM (Golden Rod) <br /> REVISED 11 /17/2003 <br />