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8))AN JOAQUIN COUNTY LINTY L' NVIN% 0NMFN /AAL A d1dAI.& O-I LSI PARTMENT <br /> Type of Business or Property FACILITY ID # SERVICE REQUEST # <br /> Retail Fuel FAPOO ( <br /> OWNER / OP <br /> ( 5ikT%top Markets / Martin Hilfingr CHECK if BILLING ADDRESS -- i <br /> FACILITY NAME Quik Stop 124 <br /> SITE ADDRESS 505 N Main St . 95336 <br /> Manteca <br /> Street Number Direction Street Name City Zlo Code <br /> HOME or MAILING ADDRESS (if Different from Site Address) 165 Flanders Road <br /> Street Number Street Name <br /> CITY Westborough MTATE ziP01581 <br /> PHONE #1 EXT* APN # LAND USE APPLICATION # <br /> (209 ) 823 -7628 store <br /> PHONE #2 ExT. BOS DISTRICT LOCATION CODE <br /> ( 50 ) 270-4444 Martin Hillfinger <br /> CONTRACTOR / SERVICE REQUESTOR <br /> Re° 6arOR <br /> rie Miller <br /> CHECK if BILLING ADDRESS <br /> BUSINESS NAME Elite IV Contractors PHONE # EXT. <br /> ( 2095 461 -6337 <br /> HOME or MAILING ADDRESS <br /> 2535 Wigwam Dr ( 209461 -6337 <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 JOPAYMENT <br /> COUNTY Ordinance Codes, Standards, STATE and FEDERAL laws . RECEIVED <br /> APPLICANT' S SIGNATURE : CaIll 7de&i DATE : 11 /9/2022 N(lV 16 2022 <br /> PROPERTY I BUSINESS OWNER ❑ OPERATOR t MANAGER ❑ OTHER AUTHORIZED AGENT 0 Office Manager <br /> .nu InnnUIN COUNTY <br /> If APPLICANT is not the BILLING required PARTY, roof of authorization to sign is Title ENVIRONMENTAL <br /> p 9 HEALTH DEPARTMENT <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 : u S f — I,Il/ a c r pletiv <br /> COMMENTS : L/ T n0Y Bi <br /> LD <br /> v /'^ n^ <br /> ACCEPTED BY : EMPLOYEE #: DATE : I ZL <br /> ASSIGNED TO : AiEMPLOYEE M DATE: <br /> (t <br /> Date Service Completed (if already completed) : LZ SERVICE CODE: / C,�2W PI E:2430 67 <br /> Fee Amount : � �� Ice' Amount Paid Payment Date 1 ( 2 z_ <br /> Payment Type1 b Invoice # Ch # S Received By : <br /> EHD 48-02-025 p� � ( ZSR FORM ( Golden Rod ) <br /> 07/17/08 5N / ggg��� <br />