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SAN JOAQUIN COUNTY ENVIRONNIEN Y'AL EAk`11 I DEPARTMENT <br /> SERVICE REQUEST <br /> - - ._ . .. . .- ---------- <br /> Type of Business or Property FACILITY ID # SERVICE REQUEST # <br /> Retail Fuel rA a a 3. (o p��pp,plI <br /> OWNER / OPERATOR Jas 's Enterprise CHECK if BILLING ADDRESS@A9 <br /> FACILITY NAME Woodbridge AmPm <br /> SITE ADDRESS 18806 N . Lower Sacramento Rd Woodbridge 95258 <br /> Street Number Direction Street Name Clt ZI Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Same Street Number Street Name <br /> CITY STATE zip <br /> PHONE #1 EXT. APN # LAND USE APPLICATION # <br /> (209 ) 339 -8238 <br /> PHONE #2 EXT, BOS DISTRICTLOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR Carrie Miller CHECK if BILLING ADDRESSP <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 /> 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 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 : cam wk&? - DATE : 11 /21 /2022 <br /> PROPERTY / BUSINESS OWNER ® OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT Ef 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 to me Or <br /> my representative . <br /> TYPE OF SERVICE REQUESTED : s' T �� � ��� PAYMEN <br /> COMMENTS : IJ 0 L (.�L,J S <br /> ' \ <br /> ( K.f' ��rY„E�i/�,[Q NOV 2 2 22 <br /> SAN JOAQUIN COU Jl Y <br /> ENVIRONNIENTA - <br /> HEALTH DEPARTM - NI <br /> ACCEPTED BY : ta EMPLOYEE # : DATE : a� 2 � <br /> ASSIGNED TO : ,� /} ( EMPLOYEE # : DATE : <br /> Date Service Completed ( if already completed) : 1? 2Z SERVICE CODE: - 29� PIE: zoo <br /> Fee Amount : ' a' Amount Paid {�6 l Payment Date <br /> Payment Type (� Invoice # Cpe,61 # Sa 6 `�/ $ 7j;� Received By: <br /> ll Zo 2, 'L <br /> EHD 48-02-025 SR FORM (Golden Rod ) <br /> 07/17/08 <br />