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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # SERVICE REQUEST # <br /> vs4r � �aa� � 0Koo a <br /> 40 <br /> OWNER / OPERATOR <br /> Pari Judge CHECK If BILLING ADDRESS <br /> FACILITY NAME BAP ENTERPRISES INC/WILSON WAY CHEVRON <br /> SIE DRES N . Wilson way 95205 <br /> treat Number Direction Street Name Stockton Zip Code <br /> HOME Or MAILING ADDRESS ( If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE #1 EXT. API # LAND USE APPLICATION # <br /> ( 209) 942 -2344 <br /> PHONE #2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> Olivia Marie Ojeda CHECK If BILLING ADDRESS <br /> BUSINESS NAME ElitelV Contractors PHONE # EXT. <br /> -4 209 461 �6337 <br /> HOME or MAILING ADDRESS FAX # <br /> 2535 Wigwam Dr ( 209) 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 /> 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, STAT and FEDERAL laws . <br /> APPLICANT'S SIGNATURE : 6 Irz DATE : 6-27-2019 <br /> PROPERTY / BUSINESS OWNER ❑ OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT ❑ Service Coorinator <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 /> 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 : �' 4 <br /> COMMENTS : �0 e <br /> 019AN4� 7 ?O NCO <br /> FMTq4N1Y <br /> ACCEPTED BY: t EMPLOYEE #: t DATE : 7 <br /> ASSIGNED TO : EMPLOYEE #: / / DATE: ' 7 Z � - <br /> Date Service Completed (if already completed ) : SERVICE CODE : ! � PIE: ®g <br /> Fee Amount: ✓ 2 GU Amount Pai ! Payment Date <br /> Payment Type ; 's� Invoice # Check # 172503 Received By : <br /> EHD 48-02-025 SR FORM (Golden Rod) <br /> 07/17/08 <br />