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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 � ( � � 1Z Ui FJ <br /> OWNER / OPERATOR <br /> Rinku CHECKif BILLING ADDRESS ® <br /> FACILITY NAME <br /> MCM14 Corp - Arco <br /> SITE ADDRESS 130 Wilson Way Stockton 95205 <br /> Street Number Direction I Street Name Cit Zip 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 ) 466 -6633 <br /> PHONE #2 EXT• BOS DISTRICT LOCATION CODE <br /> (916 ) 607 -3245 <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR Carrie Miller CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE # EXT. <br /> Elite IV Contractors 209 461 -6337 <br /> HOME Or MAILING ADDRESS FAX # <br /> 2535 Wigwam Dr ( 20461 -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 : C4404 7Ak&aA� DATE: 2/16/2024 <br /> PROPERTY f BUSINESS OWNER ❑ OPERATOR f MANAGER ❑ OTHER AUTHORIZED AGENT 1�` 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 i5 provided t0 me Or <br /> my representative . <br /> TYPE OF SERVICE REQUESTED : 7 <br /> COMMENTS : <br /> ACCEPTED BY : EMPLOYEE M DATE: <br /> ASSIGNED TO: r r/ • EMPLOYEE #: DATE: <br /> Date Service Completed (if already completed) : SERVICE CODE : <br /> jqcf �� Q PIE: /� � <br /> Fee Amount: �,�' Do Amount Paid Payment Date �! <br /> Payment Type Invoice # Check # Received By : <br /> EHD 48-02-025 SR FORM (Golden Rod ) <br /> 07/17/08 <br />