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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 M).29S R0Q) $ 5 <br /> OWNER / OPERATOR Lawrence Wight CHECK if BILLING ADDRESS ❑ <br /> FACILITY NAME Wight Holding Inc . <br /> SITE ADDRESS W Stockton 95207 <br /> 2908 Benjamin Holt Dr. <br /> Street Number Direction Street Name City Zin Code <br /> HOME or MAILING ADDRESS (if Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE zip <br /> PHONE #1 EXT• APN # LAND USE APPLICATION # <br /> ( 209 ) 478- 5552 <br /> PHONE #2 EXT BOS DISTRICT LOCATION CODE <br /> ( 209 ) 993 -7825 <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR Carrie Miller CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE # Exr. <br /> Elite IV Contractors 209061 -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 : C44Azoq 7& DATE : 2/ 16/2024 <br /> PROPERTY / BUSINESS OWNER ❑ OPERATOR I MANAGER ❑ OTHER AUTHORIZED AGENT ' 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 timQ{f *s_ provided to me or <br /> my representative . !"'A �IC <br /> TYPE OF SERVICE REQUESTED ; 1 ,? L `I <br /> COMMENTS : L+ j FEB 22 2024 <br /> SAN <br /> i0AQUIN C <br /> HEALTH ONrOE TA <br /> Ty <br /> EpA N7 <br /> ACCEPTED BY : SL Oct �� . 1��� EMPLOYEE #: DATE : / j d;v4 <br /> ASSIGNED TO : ��� `' _ ��a e- a� EMPLOYEE #: DATE: 42 / V <br /> Date Service Completed ( if already completed) : Al SERVICE CODE 4`f PIE: 3 0' <br /> Fee Amount: dz7 Amount Paid 70fO QD Payment Date a (� <br /> Payment Type 5� Invoice # Check # I � (P �2 _S7 Received By: <br /> EHD 48-02-025 SR FORM (Golden Rod ) <br /> 07/17/08 <br />