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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST CC L3 4I <br /> Type of Business or Property -� T - FACILITY ID #� SERVICE REQUEST #� <br /> Retail Fuel OQ 21 R ! <br /> OWNER / OPERATOR Jess Diaz ^ � CfrECK If (31LLINn AOORCSS <br /> FACILITY NAME Loves Travel Center 0538 <br /> SITE ADDRESS 15250 N Thornton Road Lodi F95242 <br /> SirealNumber SOWN a i i Coda <br /> HOME or MAILING ADDRES'�(IItt0Different from Site Address) N . Pen d Xa a is Ave <br /> Street Number F � <br /> CITY Oklahoma City STATE 79T20 <br /> PHONE #1 Ezr. APN # LAND USE APPLICATION # <br /> (209 ) 333-9392 Site <br /> PHDNEN2 .IeSSY-DIaZ Gell BOSDISTRICT LOCATION CODE <br /> (405) 687- 1060 <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTORCarrie Miller CHECK If BILLING ADDRESS [:] <br /> PI10HE fI EXT' <br /> auslNEssNAME Elite IV Contractors 209 461 -6337 <br /> HOME or IVIAILINGADDRESS 2535 Wigwam Dr FaxII <br /> ( 209) 461 -6342 <br /> CITY Stockton STATE CA ZIP95205 <br /> BILLING ACKNOWLEDGEMENT: 10 the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site andlor 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 /> I 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 EDERAL WS. <br /> APPLICANT'S SIGNATURE : DATE: <br /> PROPERTY / BUSINESS OWNER,O <br /> CPERATANAGER <br /> OTHER AUTHORIZED AGENT D ih / IrOhhCh' r1 qfQ (L <br /> B1LLl TYifPPucAnrrisnotthe PAR <br /> proof of authorkatlon to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, 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 enviranmentallslte assessmenLin <br /> rmaGon <br /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the same time it i5 provi �� <br /> my representative . cT <br /> TYPE OF SERVICE REQUESTED: �V 4 <br /> COMMENTS: SAN 1 ? �� <br /> (S NVlRoNM C LINTY <br /> ALTydEPART ENT <br /> ACCEPTED BY: - � <br /> EMPLOYEE *: DATE: fl � / 2 <br /> ASSIGNED TO : S �Q` �`'Q EMPLOYEE: DATE: / / ZJ <br /> Date Service Completed (if already completed): SERVICE CODE: <br /> Fee Amount: `=" 'Amount Paid L� W Payment Date 23 <br /> Payment Type ��� Invoice # Check # d By: <br /> EHD 4&02-025 SR FORM (Golden Rod) <br /> OTI1ND6 <br />