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SAN JOAQUIN COUNTY ENVIRONAIENTAL HEALTH DEPARTNIENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # SERVICE REQU�ESoT�# <br /> Gas & Food Retail ROD( <br /> OWNER / OPERATOR <br /> Ashish Bove a CHECK If BILLING ADDRESS ® <br /> FACILITY NAME <br /> Mv Mini Mart <br /> SITE ADDRESS 1756 NWilson Way Stockton 95205 <br /> Street Number Direction Street 'Na a City Zip Code <br /> HOME or MAILING ADDRESS ( if Different from Site Address) <br /> same as above Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE #1 EXT* APN # LAND USE APPLICATION # <br /> ( 209 ) 941 -2264 <br /> PHONE #2 Ext BOS DISTRICT LOCATION CODE <br /> ( 408 ) 204 - 1636 <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> Deborah Jones CHECK If BILLING ADDRESS LI <br /> BUSINESS NAME PHONE # EXT, <br /> Elite IV Contractors 209 461 -6337 _ <br /> HOME or MAILING ADDRESS FAx # <br /> 2535 Wi wam Drive ( 209 ) 461 -6342 <br /> CITY Stockton CA STATE 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 <br /> or 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 clone in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Slandards , STATE and FEDERAL laws. <br /> APPLICANT' S SIGNATURE : , DATE : 4/02/2021 <br /> PROPERTY / BUsINESs OWNER 13 OPERATOJJIANAGIsR OTHERAUTHORizrDAGENT ® Administrative Assistant <br /> If APPLICAN7' is not the BILLING PARTY, proof of authorization to sign is required Tine <br /> AUTHORIZATION TO RELEASE INI+ORMATION , When applicable, I , the owner or operator of the property located at the <br /> above site address , hereby authorize the release of any and all results , geotechnical data and/or environmental/site assessment <br /> information t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as Soon as it is available and at the same time it is <br /> provided to me or my representative . <br /> TYPE OF SERVICE REQUESTED : U Ay FLOT4V PA y <br /> COMMENTS : CEI V <br /> ED <br /> APR 0 ? 2021 <br /> SAN ,t116AL. TjqNoRONMCCDNNTy <br /> TAS <br /> ACCEPTED BY : E,+ v EMPLOYEE #: DATE: UIVNT <br /> ASSIGNED TO: i v EMPLOYEE # : DATE : <br /> Date Service Completed (ifh eady completed ) : SERVICE CODE : lq, (f <br /> PIE : <br /> Fee Amount: (� � �� Amount Paid Jx �/ Payment Date Z;Z4 <br /> Payment Type Invoice # Check # 12,, , Received By : <br /> EHD 48-02-025 SR FORM ( Golden Rod ) <br /> REVISED 11 / 17/2003 <br />