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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # SERVICE REQUEST # <br /> Q <br /> Retail Fuel Oct 00 2S <br /> OWNER / OPERATOR Nicholas Cragg CHECK if BILLING ADDRESS ❑ <br /> FACILITY NAME Stop N Shop <br /> SITE ADDRESS 1856W Country Club Stockton 95204 <br /> Street Number Direction I a City Zip 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 ) 981 -3433 <br /> PHONE #2 EXT• BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR Carrie Miller CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE # EXT, <br /> Elite IV Contractors 1 2091 461 -6337 <br /> HOME or MAILING ADDRESS FAX # <br /> 2535 Wigwam Dr ( 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 : CMZ WkZti DATE : 01 / 12/2023 <br /> PROPERTY / BUSINESS OWNER ❑ OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT 0 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 t0 me Or <br /> my representative . <br /> TYPE OF SERVICE REQUESTED : <br /> COMMENTS : / V ED <br /> JAN 1 3 2023 <br /> SAN 104 QL/ <br /> HEN RONMOOONTy <br /> �1 LTH pEpq ENTAL <br /> ACCEPTED BY : . \ fiy1 !, V EMPLOYEE M DATE: <br /> ASSIGNED TO: o til , IL EMPLOYEE M DATE: A z3 <br /> Date Service Completed ( If already completed) : SERVICE CODE: le7i �29f P1 E: 23 B 0 <br /> Fee Amount: emteF °v Amount Paid 76g . Com/ Payment Date V/2)/Ls <br /> Payment Type j '4)&� Invoice # Check # 15� Rel <br /> By: <br /> 1555 � v � 3 g <br /> EHD 48-02.025 SR FORM (Golden Rod ) <br /> 07/17/08 <br />