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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # SERVICE REQUEST # <br /> Fi9�bUO2 L/ e f t► 'u 5 5 <br /> OWNER / OPERATOR <br /> Ranvir " Ray" Rana CHECK If BILLING ADDRESS <br /> FACILITY NAME Shop N Go <br /> SITE ADDRESS 4511 Pacific Ave Stockton 95207 <br /> Street Number Direction I Street Name city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE #1 ExT• APN # LAND USE APPLICATION # <br /> ( ) 209 -952-0001 <br /> PHONE #2 Exr. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> 916-821-477111U _ <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR John Baylis CHECK if BILLING ADDRESS <br /> BUSINESS NAME IEC Services PHONE # Exr. <br /> ( 916 ) 993 - 6312 <br /> HOME or MAILING ADDRESS 4901 Warehouse Way, FAx # <br /> CITY Sacramento, STATE CA ZIP 95826 <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 : �& U DATE : 5/23/22 <br /> PROPERTY / BUSINESS OWNER ❑ PERATOR / M AGER ❑ OTHER AUTHORIZED AGENT 66 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 <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 an at the same time it is <br /> provided to me or my representative . ,q <br /> TYPE OF SERVICE REQUESTED : <br /> COMMENTS : Mq L O <br /> yFFN/o Q/ 3 20?? <br /> A4TN�,/V, /V <br /> MFN <br /> ACCEPTED BY: sta - 'l/� f���� EMPLOYEE #: DATE : 2a 2 a <br /> ASSIGNED TO : `_ j j Rlvl <br /> /1 EMPLOYEE # : DATE : Z � , <br /> Date Service Complete (if already completed) : SERVICE CODE : e7O .2e7 f P I E: 2 � <br /> Fee Amount: eyv Amount Pai 4U / Payment Date 23 ZZ <br /> Payment Type _ Invoice # Check # 1D 3 � eceived By: <br /> EHD 48-02-025 SR FORM (Golden Rod ) <br /> REVISED 11 /17/2003 <br />