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SAN JOACZUIN COUNTY ENVIRONMENTAL CAEAL`ri -I DEPARTMENT <br /> �. RVIGF� REQUEST <br /> Type of Business or Property FACILITY ID # SERVICE REQUEST It <br /> 0 200 <br /> OWNER / OPERATOR <br /> Angle CHECI( If BILLING ADDRESS <br /> FACILITY NAME EI Dorado Gas and Mart <br /> SITE ADDRESS 1605 S EI Dorado St 95206 e <br /> Street Number Direction Street Name Stocl<tO Zin <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 /> ( 2091 939- 1906 <br /> PHONE #2 ExT• BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> Megan Mitchell CHECICifBILLING ADDRESS <br /> BUSINESS NAME PHONE # Ext, <br /> Elite IV Contractors <br /> ( 209 ABL327 <br /> HOME or MAILING ADDRESS FAx <br /> 2535 Wigwam Dr ( 209. 4RU6342 <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 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 : - 9/ 112020 <br /> PROPERTY I BUSINESS OWNER ❑ O ERATOR I MANAG R OTHER AUTHORIZED AGENT ER nffice Assistant <br /> If APPLICANT iS O��the" ILLING PARTY, proof of authorization to sign is required <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 jvide d to me or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED : <br /> COINAENTS: <br /> sEF � y 2D20 <br /> SAN j0A <br /> HE LTH ONM�NOTANTy <br /> DEPARTMENT <br /> ACCEPTED BY : , - v� � EMPLOYEE #: DATE: <br /> ASSIGNED TO : f /] �/ EMPLOYEE # : DATE : // X� <br /> Date Service Completed-4 �alreadycoted) : SERVICE CODE : /' `'' PIE <br /> Fee Amount : `1f °a Amount Paid �/�, bD Payment Date 9 / T <br /> Payment Type � ._ Invoice # Check # 1 /3 � �q Received By: <br /> EHD 48-02-025 SR FORM (Golden Rod ) <br /> 07/17/08 <br />