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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # SERVICE REQUEST # <br /> Fuel Retail {]/') Aq I I l <br /> OWNER / OPERATOR /`'i•� <br /> Hardeep CHECK if BILLING ADDRESS <br /> FACILITY NAME B&G Group <br /> SITEADDRESS 116 Roth Rd Lathrop 95330 <br /> Street Number Direction Street Name City ZI Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CIN STATE ZIP <br /> PHONE #1 ExT. APN # LAND USE APPLICATION # <br /> ( 707 ) 326-0369 <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 # EXT. <br /> 209 461 -6337 <br /> HOME or MAILING ADDRESS FAX # <br /> 2535 Wigwam Dr <br /> ( 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 /> 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 . e, <br /> APPLICANT' S SIGNATURE : 7� � DATE *61 9 C) l f <br /> PROPERTY I 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 , 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 pillbVed to me or <br /> my representative . <br /> TYPE OF SERVICE REQUESTED : <br /> COMMENTS: 46s,�✓ 0 <br /> Ro��N 9 49 <br /> ACCEPTED BY : R j vz4*;z� EMPLOYEE # : DATE: <br /> ASSIGNED TO: u,Q` ��� EMPLOYEEM 67yyo DATE: 9 !� <br /> Date Service Completed (if already comple ) : U SERVICE CODE : l qy, P I E:� <br /> Fee Amount: Lf�6:;p Joe Amount Pai -LZl Payment Date Sp <br /> Payment Typee:�� Invoice # Check # 9 7 / 2,7,1 Recei ed By: <br /> EHD 48-02-025 SR FORM (Golden Rod) <br /> 07/17/08 <br />