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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # ERVVI,C,E REQUESTS#} <br /> Gas Retail 1 <br /> s WLAO 5 <br /> OWNER / OPERATOR <br /> Sam Orlando CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> Orlando's Market <br /> SITE ADDRESS 18754 State Route 26 Linden 95236 <br /> Street Number Direction Street Name city Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Same as above Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE #1 ExT• APN # LAND USE APPLICATION # <br /> ( 209 ) 887- 1100 1 <br /> PHONE #2 ExT• BOS DISTRILOCATION ODE <br /> ( ) 601 � <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUEah Jones STOR CHECK If BILLING ADDRESS 0 <br /> DeborBUSINESS NAME PHONE # Emu <br /> Elite IV Contractors 209 1 461 -6337 <br /> HOME Or MAILING ADDRESS FAX # <br /> 2325 Wigwam Drive ( 209 ) 461 -6342 <br /> CIN 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 : T 11.`Le DATE: 9/28/2021 <br /> PROPERTY / BUSINESS OwNER ❑ OPERATOR / ANAGER ❑ OTHER AUTHORIZED AGENT ® 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 and at the same time it is i <br /> provided to me or my representative . P <br /> TYPE OF SERVICE REQUESTED: i�� , Y <br /> COMMENTS: Q <br /> SEP ? 8 2021 <br /> SAN <br /> FN J0AQCJ/N c <br /> NFq � TH0 P,, RTO�NTY <br /> ACCEPTED BY : EMPLOYEE #: DATE: <br /> ASSIGNED TO; ,( % EMPLOYEE #: DATE ' 1 <br /> Date Service Completed (if already completed) : ` SERVICE CODE: �! ��� P 1 E . 250 1p/1 <br /> Fee Amount: �� � 0 O Amount Pal!!? i-iL Payment Date o <br /> Payment Type invoice # Check # 32 Received y : <br /> EHD 48-02-025 SR FORM (Golden Rod) <br /> REVISED 11 /17/2003 <br />