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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # SERVICE REQUEST # <br /> OWNER / OPERATOR <br /> Hardeep CHECK If BILLING ADDRESS <br /> FACILITY NAME Fast Lane Gas & Food Mart <br /> SITE ADDRESS 116 Roth RD Lathrop 95330 <br /> Street Number Direction Street Name Cil Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) 111 Healdsburg Ave <br /> Street Number Street Name <br /> CITY Healdsburg STATE Ca ZIP 95448 <br /> PHONE #1 EXT• APN # LAND USE APPLICATION # <br /> ( 707 ) 326-0369 <br /> PHONE #2 EXT • BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR It SERVICE REQUESTOR <br /> REQUESTOR Megan M CHECK If BILLING ADDRESS <br /> PHONE # Ex <br /> BUSINESS NAME ' <br /> Elite IV Contractors 209 461 -6337 <br /> HOME or MAILING ADDRESS FAx <br /> 2535 Wigwam Dr ( 209 ) 461 -6342 <br /> CITY Stockton STATE Ca ZIP 95448 <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 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 / 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 , 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 /> p[ REQUESTED : 10 <br /> "S IVED APR 12 2019 <br /> ASR 2 6 2019 <br /> ENVIRONMENTAL. HEALTH <br /> pN JOAQUIN COUNTY <br /> ENVIRONMENTAL_ T I7FPAI TMEN I <br /> t CCEPTED BY : I ' a, -� EMPLOYEE #: C �� Q / DATE: — � b <br /> _ v� <br /> ASSIGNED TO : ( �� ) (} }� EMPLOYEE # : cc � DATE : (4 <br /> Date Service Completed ( if already completed) : SERVICE CODE: L,1 P PIE I <br /> Fee Amount : I Amount Paid Y eal, ) Z) Payment Date fl.2 f <br /> Payment Type Invoice # Check # �� �3 Received By : / l{ <br /> EHD 48-02-025 SR FORM (Golden Rod) <br /> 07/17/08 <br />