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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property t FACILITY ID # SERVICE REQUEST # <br /> JXA ( CCa294 SKOOg 137 & <br /> OWNER / OPERATOR <br /> CHECK If BILLING ADDRESS <br /> Ashish <br /> FACILITY NAME <br /> Food Mart Gasoline and Liquor <br /> SITEADDRESS 2185 E Fremont St Stockton . �. <br /> Street Number Direction Street Name City9Zi COode <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Stroet Number Street Name <br /> CITY STATE ZIP <br /> PHONE #'I EXT. APN # LAND USE APPLICATION # <br /> ( 408) 204- 1636 <br /> PHONE #2 EXT, BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> Megan Mitchell CHECK If BILLING ADDRESS <br /> BUSINESS NAME Elite IV Contractors PHONE ft EXT. <br /> ( r) nd) 4614337 <br /> HOME Or MAILING ADDRESS FAX # <br /> 2535 Wigwam Dr ( 209 461 - 6342 <br /> CITYStockton $TATE 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 /> also certify that I have prepared this application and thabthe ork to b perforfned will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards, S , ATE an FZIEDERAL <br /> J/ r <br /> APPLICANT' S SIGNATURE : l /� , l� DATE : <br /> PROPERTY / BUSINESS OWNER ❑ OPE TO / MANAGER ❑ -TER AUTHORIZED AGENT Office Assistant <br /> If APPLICANT is not the BILLINNJJG PARTY, proof of authorization to sign is required Tille <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 /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It IS available and at the Same time It IS provided t0 me Or <br /> my representative. PA ME NY <br /> TYPE OF SERVICE REQUESTED : RECEIVED <br /> ED <br /> COMMENTS : �' �r���� <br /> �l NOV 0 7 2019 <br /> SAN JOAQUIN COUNT`( <br /> ENVIRONMENTAL <br /> ^ HEALTH DEPARTMENT <br /> ACCEPTED BY : l 1� �/� <br /> EMPLOYEE DATE: / /J /q <br /> ASSIGNED TO : , S /v��� EMPLOYEE #: DATE: �I �F / l <br /> Date Service Completed ( if already completed ) : SERVICE CODE : e7 PIE: l' <br /> Fee Amount : Amount Paid ( s� -- Payment Date <br /> Payment Type 0/ Invoice # Chg& # 1 b �j�-6 Received By : <br /> EHD 48-02-025 SR FORM (Golden Rod ) <br /> 07/17/08 <br />