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SAN JOACIUIN COUNTY ENVIRONMENTAL C iI � I - I I DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # SERVICE REQUEST # <br /> Gas Station <br /> OWNER / OPERATOR Sam Hirsch CHECK If BILLING ADDRESS ® <br /> FACILITY NAME Short Stop Food Mart <br /> SITE ADDRESS 20 W Turner Rd Lodi 95240 <br /> Street Number Direction street Name city 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• APN # LAND USE APPLICATION # <br /> ( 209 ) 327-6171 � '�A � —� 0 ICD <br /> PHONE #2 ExT. BOS DISTRICT LOCATION CODE <br /> Do � ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR Megan Mitchell CHECK if BILLING ADDRESS <br /> PHONE # ExT. <br /> BUSINESS NAME Elite IV Contractors <br /> 209 461 -6337 <br /> HOME or MAILING ADDRESS FAX It <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 , STATE and FEDERAL laws . / <br /> APPLICANT' S SIGNATURE: `�G� DATE : <br /> PROPERTY / BUSINESS OWNER ❑ OPERATOR / 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 ' ormation <br /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the Same time It IS prOVId A A� <br /> my representative . <br /> TYPE OF SERVICE REQUESTED : <br /> COMMENTS : oS,gN <br /> �AlVOgQU/N <br /> NPgCTIZf?V DEPgCOU <br /> R4it <br /> ACCEPTED BY: l ' ��jJ � EMPLOYEE #: /L��/ DATE: <br /> ASSIGNED TO : VV W�! Pv ` EMPLOYEE # : O DATE: <br /> Date Service Completed ( if already completed) : SERVICE CODE: Q PiE�Z � <br /> Fee Amount: �� OU Amount PaW 4� PZ) Payment at / �7 <br /> Payment Type V ' p , Invoice # Check # 8 ?2 �s Received By : <br /> EHD 48- 02-025 SR FORM (Golden Rod ) <br /> 07/ 17/08 <br />