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SAN JOAOIJIN G OIINTY ! uN� IIVIRcONMENTAL HEALTH DEPARTMENT <br /> Type of Business or Property FACILITY ID # SERVICE REQUEST # <br /> OWNER / OPERATOR Rupi Padda <br /> CHEC!< If BILLING ADDRESS ® <br /> FACILITY NAME :Flag City Shell <br /> SITE ADDRESS 6437 Banner St <br /> Lodi [95242 <br /> Streat Number Directi n Street Name Cit ZIP <br /> i Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Sfreet Number Street Name <br /> CITY STATE ZIP <br /> PHONE #1 ExT. APN # LAND USE APPLICATION # <br /> ( 209 ) 914 -8735 <br /> PHONE #2 ExT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR It SERVICE REQUESTOR <br /> REQUESTOR Megan Mitchell <br /> CHECK If BILLING ADDRESS ® <br /> BUSINESS NAME Elite IV Contractors PHONEft Exr , <br /> 209 461 -6337 <br /> HOME Or MAILING ADDRESS 2535 Wigwam Dr FAX # <br /> ( 209 ) 461 -6342 <br /> CITY Stockton <br /> 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 : <br /> PROPERTY / BUSINESS OWNER ❑ OPERATO 1 MANAGER ❑ OTHER AUTHORIZED AGENT ® Office Assistant <br /> If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION : When applicable, 1 , 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 : <br /> COMMENTS ; <br /> 13AN /aA / <br /> �N QUI <br /> TiV�®F l A C00 Ty <br /> ACCEPTED BY : \ \ EMPLOYEE #: DATE : <br /> ASSIGNED TO : J NV EMPLOYEE #: DATE : Z i ?� <br /> Date Service Completed (if already completed) : SERVICE CODE ; �' PIE: / <br /> Fee Amount : ° � ' Amount Paid I <br /> (!7� Payment Date 1 l <br /> Payment Type Y5� Invoice # Check # Received By: <br /> 105 / 21 Z57 <br /> EHD 48-02-025 <br /> 07! 17/08 SR FORM (Golden Rod ) <br />