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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 p� $ 3 SRmmB 813 <br /> OWNER / OPERATOR <br /> Jesse Singh CHECK ifBILLING ADDRESS <br /> FACILITY NAME Manteca Gas & Food <br /> SITE ADDRESS 1229 E Louise Ave Manteca 95336 <br /> Street Number Direction I Street Name Citv Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE #t EXT. APN # LAND USE APPLICATION # <br /> (209 ) 239-2233 <br /> PHONE #2 EXT. BOS DISTRICT LOCATION CODE <br /> ( 205 814 - 3730 Cell <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> Carrie Miller CHECK If BILLING ADDRESS <br /> BUSINESS NAMEElite IV Contractors PHONE # EXT, <br /> ( 209461 -6337 <br /> HOME or MAILING ADDRESS 2535 Wigwam Dr FAx # <br /> ( 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 /> 1 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 : cal2wl � 7dd&% DATE : 3/ kzlf <br /> PROPERTY / BUSINESS OWNER ❑ OPERATOR / 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 as it Is available and at the Same time it is provided t0 me or <br /> my representative. P' <br /> TYPE OF SERVICE REQUESTED : £ fi} ` CN74 <br /> COMMENTS : D <br /> 84 /V <br /> AMR <br /> 122 0 <br /> 22D <br /> NFq�T�RO/V coUN <br /> �FPq R � T Y <br /> ACCEPTED BY : s /t i �. EMPLOYEE #: DATE: 3 - i 3 - 2 4 <br /> ASSIGNED TO : Q _ EMPLOYEE #: DATE: 3 _ 13 <br /> Date Service Completed ( if already completed ) : SERVICE CODE: l 49A 11 �' PIE0 <br /> Fee Amount : L- Amount Pal L �(o �� Payment Date 3 Z <br /> Payment Type U� �� Invoice # Check # 17 �7 4-�- J (Q S Received By: <br /> EHD 48-02-025 SR FORM (Golden Rod ) <br /> 07/17/08 <br />