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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # SERVICE REQUEST # <br /> Retail Fuel 75q q 570 <br /> OWNER / OPER/5Tt1R sh GIII CHECK if BILLING ADDRESS ❑ <br /> FACILITY NAME Gil Pandher Investments dba Wine Country <br /> SITE ADDRESS E 95240 <br /> Kettleman Lane Lodi <br /> 1113 eet Number Direction Street Name City Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> SAME <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE #1 EXT• APN # LAND USE APPLICATION # <br /> ( 209 ) 369- 3633 Site <br /> PHONE #2 EXT, BOS DISTRICT LOCATION CODE <br /> ( 209 ) 300-3738 - Gill <br /> CONTRACTOR It SERVICE REQUESTOR <br /> REQUESTOR <br /> Carrie Miller CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE # EXT. <br /> Elite IV Contractors I 20 %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 : Ca4 Nd&4� DATE : 8/ 15/2023 <br /> PROPERTY I BUSINESS OWNER ❑ OPERATOR I 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 /> 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 . P <br /> MW <br /> TYPE OF SERVICE REQUESTED : S �' ECE <br /> vprl <br /> COMMENTS : P <br /> AUG 2 3 1013 <br /> SAN JOAQUIN C <br /> HEgLTN pEpAE ENT <br /> ACCEPTED BY: ` EMPLOYEE #: DATE: <br /> ASSIGNED TO : r EMPLOYEE # : DATE: 1 Lfi 2-Z) <br /> Date Service Completed (If beady completed) : SERVICE CODE: (q 2 ( g PI Ee; <br /> Fee Amount : S "G Amount Pal g� , b � Payment Date 2� <br /> Payment Type , Invoice # Check # �� 2 .957 � Received By : <br /> EHD 48-02-025 SR FORM (Golden Rod ) <br /> 07/17/08 <br />