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SAN JOAQUIN COUNTY ENVIRONMCNTAL I IEALil1 DEPARTMENT <br /> SERVICL LOUES T <br /> Type of Business or Property FACILITY ID # SERVICE REQUEST # <br /> OWNER / OPERATOR <br /> Venus CHECK if BILLING ADDRESSIA <br /> FACILITY NAME Sinclair <br /> SITE ADDRESS 1001 E Yosemite Ave Stockt 95336 <br /> Street Number Direction Stroet Name �Il � ZI Codc <br /> HOME or MAILING ADDRESS (if Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE #'I EXT. APN # LAND USE APPLICATION # <br /> ( 200 225 -8513 <br /> PHONE #2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUEST® R <br /> REQUESTOR <br /> Megan Mitchell CHECK IfBILLING ADDRESS <br /> BUSINESS NAME PHONE # EXT, <br /> Elite IV Contractors <br /> HOME or MAILING ADDRESS FAX # <br /> 2535 Wigwam Dr ( 200) ML634 ? <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 /> I also certify that I have prepared this application and that the wo k'fo be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards, STATE and FEDERAL laws <br /> APPLICANT' S SIGNATURE : � /PARTY, <br /> /L2/ �� — DATE: <br /> PROPERTY / BUSINESS OWNER ❑ OPER / MANAGER - ` OTHER AUTHORIZED AGENT <br /> If APPLICANT is not the BILLYproof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFOATION : 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 to me or <br /> my representative . <br /> TYPE OF SERVICE REQUESTED : USF <br /> COMMENTS: LZ LJ <br /> SEP 4 2020 <br /> NENAONM�N�A NT <br /> RT <br /> ACCEPTED BY : ` 14V /r �/� EMPLOYEE M DATE : <br /> ASSIGNED TO : Ta. wftAMKV�rs� EMPLOYEE M DATE : 111 <br /> Date Service Completed ( if already completed) : SERVICE CODE : G �✓ PIE : <br /> Fee Amount : OV Amount Paid �SG. �0 Payment Date <br /> Payment Type1 { 5� Invoice # Check # / 72. Received By : <br /> EHD 48-02-025 SR FORM (Golden Rod) <br /> 07/17/08 <br />