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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 009W 2� <br /> OWNER / OPERATOR Muhammad Rizwan CHECK If BILLING ADDRESS ❑ <br /> FACILITY NAME SRH Food & Gas Market <br /> SITE ADDRESS <br /> 749 E Dr, Martin Luther King Blvd Stockton 95206 <br /> Street Number Direction I Street Name 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, rF�N # LAND USE APPLICATION # <br /> ( 209 ) 465-8979 <br /> PHONE #T EXT, BOS DISTRICT LOCATION CODE <br /> ( 209 ) 271 =2578 Cell Phone �7 <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> Carrie Miller CHECK if BILLING ADDRESS <br /> BUSINESS NAME Elite IV Contractors PHONE # EXT. <br /> 209 461 =6337 <br /> HOME or MAILING ADDRESS FAX # <br /> 2535 Wigwam 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 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 : Cbz 7e 4- DATE : 4/13/2023 <br /> PROPERTY / BUSINESS OWNER ❑ OPERATOR I 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 /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as Soon a5 it is available and at the Same time it IS provided to me Or <br /> my representative. tA VAN ANN <br /> all V/11F <br /> TYPE OF SERVICE REQUESTED : fY1j • \ Ccp , A1 7* <br /> COMMENTS : <br /> (1 071 V JFrx�e� � � � ��� <br /> (�C S OR 1 3 ?0?3 <br /> EIV AQUIIV c <br /> HEALTH D 4E�T4L Ty <br /> ACCEPTED Bye <br /> :` � EMPLOYEE DATE: <br /> ASSIGNED TO : VV t- `�1A EMPLOYEE M �j DATE: <br /> Date Service Completed (if already completed) : _ . SERVICE CODE: j �' ?G, S _ IP 1 E: L �7 <br /> Fee Amount: �O Amount Paid $ �� Payment Date 13 <br /> Payment Type Vi '4yInvoice # Check # I D ' 7973T I Received By : al 0 <br /> EHD 4&02-025 SR FORM (Golden Rod) <br /> 07/17/08 <br />