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i <br /> SAN JOAC1UIN COUNT Y ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID It SERVICE REQUEST # <br /> Retail Fuel of awl sQ uo� SS23 <br /> OWNER / OPERATOR Bob & Kathy Lutz CHECK if BILLING ADDRESS ® <br /> FACILITY NAME ElDorado Food Mart <br /> SITED FSS N EI Dorado St . Stockton <br /> U 95204 <br /> Street Number Direction Street Name City ZI COPA <br /> HOME or MAILING ADDRESS (If Different from Site Address) �, � FNT <br /> lDSame Street Number Street Name VE <br /> CITY STATE ZIP JUL <br /> PHONE #1 EXT, APN # LAND USE APPLICATION # SAN JO �U2C <br /> N ENV/RO UI ! COON( 209 ) 943 - 1311 NAI CO NTy <br /> PHONE #2 EXT, BOS DISTRICT <br /> LOCATION CODE P RrMENr <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> Carrie Miller CHECK if BILLING ADDRESS <br /> BUSINESS NAME Elite IV Contractors PHONE # EXT. <br /> ( 209Y461 -6337 <br /> HOME or MAILING ADDRESS 2535 Wigwam Dr Stockton , Ca 95205 FAx # <br /> ( 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/Gr 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 /> 1 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 : Ca4e, weir- DATE : 7/ 13/2022 <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 provided t0 me Or <br /> my representative . <br /> I <br /> TYPE OF SERVICE REQUESTED : �4S ' <br /> COIANIENTS : ' l <br /> ar eea utiz�/��29 /�I fa p/�'� '7c� 10e j M / 1c,� Zvi Y4 <br /> �J 1 <br /> I <br /> ACCEPTED BY : Jai \ `. EMPLOYEE # : DATE : <br /> L L T �/ 7 7 � <br /> ASSIGNED TO : f EMPLOYEE #: DATE : 7 2 <br /> Date Service Comp eted ( if already completed) . SERVICE CODE: G�;f 29� PIE 0 � <br /> Fee Amount: ( C� D Amount Paidq=p L Payment Date 7 i <br /> Payment Type _ Invoice # Check # ' 459000 Received By: <br /> EHD 48-02-025 SR FORM (Golden Rod ) <br /> 07/17/08 <br /> 1 <br />