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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 _ 54VOOM32 7 5 'Rmm 5 7 5 3 7 <br /> OWNER / OPERATOR <br /> CHECK If BILLING ADDRESS ® <br /> Jesse Singh <br /> FACILITY NAME <br /> Manteca Gas & Food <br /> SITE ADDRESS 1229 E & ! 4wP Louise Ave95336 <br /> Manteca <br /> Street Number Direction I 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 ) 239 -2233 Store <br /> PHONE #2 ExT• BOS DISTRICT LOCATION CODE <br /> ( 209 ) 814 - 3730 Cell <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> Carrie Miller CHECK if BILLING�14 <br /> ADDRESS <br /> BUSINESS NAME PHONE # EXT, <br /> Elite IV Contractors 20 %461 -6337 <br /> HOME or MAILING ADDRESS FAX # <br /> 2535 Wigwam Dr ( 209 ) 461 -6342 <br /> _ <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 applic "a"tion 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 : �� /� , L ( � IGL � DATE : ��/ _5 <br /> PROPERTY / BUSINESS OWNER ❑ OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT CJ 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 a5 It is available and at the Same time It IS provided t0 me or <br /> my representative . <br /> TYPE OF SERVICE REQUESTED . �'r /� �� Rlrll <br /> COMMENTS : �O L�- / ® D <br /> Jo c ' S 202 <br /> HSA Ty D�pgSN ��N Y <br /> Rr <br /> ACCEPTED BY : EMPLOYEE #: DATE : 2 73 <br /> ASSIGNED TO : n i / J EMPLOYEE #: DATE : <br /> Date Service Completed ( if already completed ) : SERVICE CODE/ G�'� PIE: <br /> Fee Amount : ' / ( 2 ` e Amount Pal ` � Z , (�� Payment Date y3 <br /> Payment Type Invoice # Check # � 7L� � � � a7 Recerive6l By : <br /> EHD 48-02-025 SR FORM ( Golden Rod ) <br /> 07/ 17/08 <br />