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i <br /> i <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # SERVICE REQUEST # <br /> Convenient Store and Retail Fuel 7 VD? 0r� Gq �.� � Li LA '2 <br /> OWNER / OPERATOR <br /> Jesse Diaz - Love's CHECK if BILLINGADDRES: <br /> FACILITYNAME Love's Travel Stop Ripon <br /> SITEADDRESS 1553 Colony Rd Ripon 95366 <br /> Street Numbar Direction Street Name city Zin Code <br /> HOME Or MAILING ADDRESS ( If Different from Site Address) <br /> P . O . Box 26210 Street Number Street Name <br /> CITY STATE ZIP <br /> Oklahoma City , OK 73126 <br /> PHONE #1 EXr. APN It LAND USE APPLICATION # <br /> ( 405) 687- 1060 245 -340 -24 23819 <br /> PHONE #2 EXT• BOS DISTRICT LOCATION CODE <br /> .. n C) 5 <br /> ( ) <br /> CONTRACTOR / SERVICE REI QUESTOR <br /> REQUESTOR CHECK If BILLING ADDRES;. X <br /> Jamie Barnes <br /> BUSINESS NAME PHONE # Exr' <br /> HFA <br /> HOME or MAILING ADDRESS FAX # <br /> 1705 S Walton Blvd Ste 3 ( ) <br /> CITY Bentonville STATE AR ZIP 72712 <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 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 : DATE : 10-28 -2021 <br /> PROPERTY / BUSINESS OWNER ❑ OPERATO=MANAGER OTHER AUTHORIZED AGENT <br /> ® Architect/Engineering Firm <br /> If APPLICANT is not the BILLING Pf 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 /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it Is Arovided to me or <br /> my representative . N <br /> TYPE OF SERVICE REQUESTED : <br /> COMMENTS : 00T CJ <br /> sF `/C <br /> �yFq T(NO�q FN;hvTY <br /> RTMF <br /> ACCEPTED BY: � t CCS �� V L�r�� EMPLOYEE M DATE: 1012 z, <br /> ASSIGNED TO : 1J �� EMPLOYEE #: DATE:�40-6 <br /> Date Service Completed (if already completed) : _ - SERVICE CODE' / C��'' Zq P 1 E. ,TQC' <br /> Fee Amount : ? y)/ > G' �' Amount Paid L � ObPayment Date 102 <br /> Payment Type 5� Invoice # Check # / Received By: <br /> EHD 48-02-025 SR FORM (Golden Rod) <br /> 07/17/08 <br />