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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # SERVICE REQUEST # <br /> Retail Fuel <br /> OWNER / OPERATOR <br /> Sam Orlando CHECK if BILLING ADDRESS <br /> FACILITY NAME Orlandos <br /> SITE ADDRESS E Linden <br /> HVVY26 95236 <br /> 18754 <br /> Street Number Direction I Street Name City Zig) Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> P . O . Box 1500 Street Number S rest Name <br /> CITY Linden STT`ATE zip 95236 <br /> PHONE #1 ExT. APN # LAND USE APPLICATION # <br /> ( 209 ) 887- 1100 <br /> PHONE #2 EXT• BOS DISTRICT LOCATION CODE <br /> ( 916) 708-4999 <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR Carrie Miller CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE # ExT. <br /> Elite IV Contractors 209 461 -6337 <br /> HOME or MAILING ADDRESS 2535 Wigwam Dr FAX # <br /> ( 209 ) 461 -6342 <br /> CITE' 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 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 : 8/ 18/2022 <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 /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as Soon as it IS available and at the Same time it Is gfovided to me or <br /> my representative. / 4 A , <br /> TYPE OF SERVICE REQUESTED: Li+'f / Pit / , vt [ 1. " V141 <br /> ' y <br /> COMMENTS : too" i2 _ � S,// /7/l �+ � 4� <br /> Sqj, <br /> i i7 �NJ°� <br /> 6V <br /> °�NTJ. <br /> RTMEN <br /> ACCEPTED BY : i EMPLOYEE M DATE: <br /> ASSIGNED TO . kiwice Ya (A1� o i EMPLOYEE M DATE: „Z <br /> Date Service Completed (if already completed) : SERVICE CODE: 2�0 PI E: � <br /> Fee Amount : �j Amount Pa 7 S Payment Date Y31 �2 <br /> Payment Type ��� Invoice # Check # g S� / b Received By: <br /> �2 Z <br /> EHD 48-02-025 SR FORM (Golden Rod ) <br /> 07/17/08 <br />