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6AN , ilOACIIIIN COUNTY ENVIRONMENTAL. HEHALTH DEPAtJ & HVIENT <br /> SE3 R V0 cC, F R (ck GT <br /> Type of Business or Property FACILITY ID # ERVICE REQUEST # <br /> Retail Fuel <br /> SP00 c 2 �l <br /> OWNER / OPERATOR <br /> CHECK If BILLING ADDRESS rni <br /> FACILITY NAME Delta Arco <br /> SITE ADDRE2P40 Dr Mrtin Luther King Jr Blvd Stockton 95206 <br /> Street Number Dir, Street Name Cit 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 ) 465 -2487 <br /> PHONE #2 EXT• BOS DISTRICT LOCATION CODE <br /> (209 ) 594-2100 - Jay <br /> CONTRACTOR / SERVICE RE, QUESTOR <br /> REQUESTOR Carrie Miller <br /> CFlEC!< If BILLING ADDRESS <br /> BUSINESS NAME PHONE ft ExT. <br /> Elite IV Contractors 209 461 -6337 <br /> HOME or MAILING ADDRESS FAX # <br /> 2535 VVigwam Dr ( ) <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 thisap Ica n and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards, S ATE and FEDERAL laws. <br /> v <br /> APPLICANT' S SIGNATURE : il ' ' DATE : 5/6/2022 <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 provided t0 me or <br /> my representative . bAx <br /> TYPE OF SERVICE REQUESTED : EI <br /> COMMENTS : E0 <br /> MAY <br /> ® g ZSAN /O4022 <br /> gLQMHETNOpNNT <br /> YO <br /> ACCEPTED BY : EMPLOYEE #: DATE _7 <br /> - Z L <br /> ASSIGNED TO : I _ EMPLOYEE #: DATE : � 4 <br /> Date Service Completed ( if already completed) : — SERVICECODE : a7 � ;2q PIE: WPM <br /> ��� g <br /> Fee Amount : Lam) Amount Pal d _ T�l� �� Payment Date �� 7 <br /> Payment Type Invoice # Check # 7 / Received By: ]I-En <br /> EHD 48-02-025 SR FORM (Golden Rod ) <br /> 07/17/08 <br /> I <br />