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SAN JOAQUIN COUNTY ENVIRONIVIFEN ` AL HEALITI DCC PARTMENT <br /> SERVICE REAQUEST <br /> Type of Business or Property FACILITY ID # SE\R�VIIC`EREQU +STT # <br /> Retail Fuel �O 3� -I 7 �� 9 LV <br /> OWNER / OPERATOR <br /> Carlo Sharmoug CHECK if BILLING ADDRESSO <br /> FACILITY NAME <br /> Nor Cal Fuels <br /> SITEADDRESS 3300 Westlane Stockton 95204 <br /> Street NumberDlrectlon Street Name CIty ZiD 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 ) 227-5008 <br /> PHONE #2 Exr. BOS DISTRICT LOCATION CODE <br /> ( 209 ) 640 -3085 <br /> CONTRACTOR If SERVICE REQUESTOR <br /> REQUESTOR <br /> Carrie Miller CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE # EXT. <br /> Elite IV Contractors 209061 -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 : (--a Nd&4- DATE . 6/ 13/2023 <br /> PROPERTY I BUSINESS OWNER ❑ OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT [J 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 : l�V T <br /> COMMENTS : m vvW � Q� ci Ce /� Ttgg 4 -� RECEIVED <br /> JUN 15 2023 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY' /JW EMPLOYEE M DATE: <br /> ({; <br /> ACCEPTED ByjiwASSIGNED TO : ® f v� EMPLOYEE #: DATE: / (� <br /> Date Service Completed (if already completed ) : SERVICE CODE: / �29� IE: <br /> Fee Amount: t't Amount Paid Payment Dat ` a <br /> Payment Type ! Invoice # C # � '7y $ 3 tow Rec ived By: <br /> G. li3/ � a3 <br /> EHD 48-02-025 SR FORM (Golden Rod ) <br /> 07/17/08 <br />