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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 ' 1 S R ® � �} 7 5 9 <br /> OWNER / OPERATOR Jesse Singh CHECK If BILLING ADDRESS ❑ <br /> FACILITY NAME <br /> Lathrop Gas & Food <br /> SITEADDRESS 140E Lathrop Rd Lathrop 95330 <br /> Street Number Direction 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 /> PH0NE #1 EXT• APN # LAND USE APPLICATION # <br /> ( 209 ) 982 - 0052 <br /> PHONE #2 EXT. BOS DISTRICT LOCATION CODE <br /> ( 209 ) 814 - 3730 Cell 11 <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> Carrie Miller CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE # EXT. <br /> Elite IV Contractors 20 %461 -6337` <br /> HOME or MAILING ADDRESS FAX # <br /> 2535 Wigwam Dr ( 2o9 ) 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 : DATE : 2/6/2024 <br /> PROPERTY I BUSINESS OWNER ❑ OPERATOR I 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 proved to me or <br /> my representative . fillobe <br /> rvt <br /> TYPE OF SERVICE REQUESTED : us CFS <br /> COMMENTS : D <br /> 1 Cell �61Z ?j FEY 22 20 <br /> Sq �q QU/N C <br /> NEqLTy D�PMRTUS TY <br /> T <br /> ACCEPTED BY : i /{� / \ ! o��v EMPLOYEE #: DATE: 2 q Z <br /> ASSIGNED TO : �( 'V S pV -C EMPLOYEE #: DATE: <br /> Date Service Completed (if already completed) : _— SERVICE CODE: 0 �<�� P 1 E: C?�QJ <br /> Fee Amount: � L ' Amount Pai8L oD Payment Date z <br /> Payment Type Invoice # I Check # I 2 Received By: <br /> 07 ±�X 1 h <br /> EHD 48-02-025 SR FORM ( Golden Rod ) <br /> 07/17/08 <br />