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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # S <br /> SERVICE RE UEST # <br /> Retail Gas and Food O � I Rt <br /> OWNER / OPERATOR <br /> Aziz Sher CHECK if BILLING ADDRESS 0 <br /> FACILITY NAME <br /> EI Dorado Gas & Mart <br /> SITE ADDRESS 1605 S El Dorado St Stockton 95206 <br /> Street Number Direction Street Name City Zip Code <br /> HOME or MAILING ADDRESS ( If Different from Site Address) Street Number Street Name <br /> 11501 Suite 200 Dublin Blvd . <br /> CITY STATE ZIP <br /> Dublin CA 94568 <br /> PHONE #1 Exr. APN # LAND USE APPLICATION # <br /> ( 510 ) 224-6462 <br /> PHONE #2 ExT. ABOS DISTRICT LOCATION CODE <br /> 510 7514555 <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS X <br /> Deborah Jones <br /> BUSINESS NAME PHONE # ExT. <br /> Elite IV Contractors ( 209 ) 461 -6337 <br /> HOME or MAILING ADDRESS FAX # <br /> 2535 Wigwam Drive ( 209 461 -6342 <br /> CITY STATE ZIP <br /> Stockton CA 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 <br /> or 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 <br /> FEDERAL laws. <br /> APPLICANT'S SIGNATURE : Jjd LDATE : 11 /24/2020 <br /> PROPERTY / BUSINESS ON% NER ❑ OPERATOR / 6'ANAGER ❑ OTHER AUTHORIZED AGENT Fx O ice ASSIStant <br /> IfAPPLICANTis not the BILLING PARTY. proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE k MON : When applicable, I, the owner or operator of the property located at the <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and ale same time it is <br /> provided to me or my representative. J6 <br /> 4 <br /> TYPE OF SERVICE REQUESTED : lee <br /> COMMENTS: �� 0 <br /> ?0 <br /> NR NiN C �ZO <br /> O <br /> ACCEPTED BY : \ EMPLOYEE # : DATE : <br /> ASSIGNED TO : G v EMPLOYEE # : DATE : <br /> Date Service Completed if already co eted) : SERVICE CODE: f q PIE : c zw 4 <br /> Fee Amount: t3tt7 Amount Pal LZCJ Payment Date /Z// <br /> i <br /> Payment Type Invoice # Check # Received By: <br /> gun no nn noir 00 cnDRA rn ..i .+ .... D..a % <br />