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SAN JOAQUIN COUN `r y I NVIRONMF�: NTAL G ] EALTvi C) EPARTMENT <br /> SERVGF FZE0UI F ST <br /> Type of Business or Property FACILITY ID # SERVICE REQUEST # <br /> Retail Fuel rAc00(� � � Si C N q el <br /> OWNER / OPERATOR <br /> Nick Singh CHECK IfBILLING ADDRESS <br /> FACILITY NAME Country Club Mobil Circle K <br /> SITEADDRES2575 Country Club Stockton 95204 <br /> Street Number Direction Street Name Ci[ ZiCode <br /> HOME or MAILING ADDRESS ( If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE 71P <br /> PHONE #1 EXT, APN # LAND USE APPLICATION # <br /> ( 209 932 - 1307 <br /> PHONE #2 EXT* BOS DISTRICT LOCATION CODE <br /> ( 209) 838 - 5400 Nick Singh <br /> CONTRACTOR / SERVI[ CE REQUESTOR <br /> REQUESTOR <br /> Carrie Miller CHECK If BILLING ADDRESS <br /> BUSINESS NAME Elite IV Contractors PHONE # EXT, <br /> ( 20 %4611 -6337 <br /> HOME or MAILING ADDRESS 2535 Wigwam Dr Fax # <br /> ( 209461 -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 pplication and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards STATandFEDERAL laws <br /> APPLICANT' S SIGNATURE : t ��L t ' DATE : 3/4/2022 <br /> PROPERTY / 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 /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It IS available and at the Same time It IS prov ded t0 me Or <br /> my representative . <br /> TYPE OF SERVICE REQUESTED : U SfJ �'J �l/�/ D �I C � t� C� T <br /> CONVAENTS : MAR D <br /> /i zoz <br /> SAN <br /> 0gQUIN C <br /> k�ALT pEPAR7-ME rY <br /> ACCEPTED BY : kLY <br /> EMPLOYEE M DATE : 31 / z :z <br /> ASSIGNED TO : ` EMPLOYEE # : DATE : <br /> Date Service Completed ( if already completed) * SERVICE CODE : 2715 PIE: / <br /> Fee Amount : �$t` 12 `' 2j Amount Paid /� �j0 Payment Date 3 7 ZZ <br /> Payment Type � Invoice # Check # / 4 on Received By : <br /> EHD 48-02-025 SR FORM ( Golden Rod ) <br /> 07/17/08 <br />