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i <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Gas &Food Retail 1E r D 31 11 'SQ CO23LO-9 <br /> OWNER I OPERATOR <br /> Quik Stop Markets, Inc. CHECK IfBILLtNGADORESS <br /> FACIutt NAME <br /> Quik Stop Markets #138 <br /> SITE ADDRESS 1153 Lincoln Blvd. Tracy 95376 <br /> Street Number <br /> Direction <br /> Street Name CI Zi Code <br /> HOME Or MAILING ADDRESS (It Different from Site Address) 165 Flanders Road <br /> Street Number Street Nam. <br /> CITY Westborough STATE MA ZIP 01581 <br /> PHONE tit EXT. API4t# LAND USE APPuCATLON$ <br /> (508) 270-1400 4469 qo — q - <br /> PHONE#2 EXT- BOS DISTRICT LOCATION CODE <br /> l ) <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR CHECK if BILLING ADDRE550 <br /> Deborah Jones <br /> BUSINESS NAME PHONE# EAT' <br /> Elite IV Contractors 209 461-6337 <br /> HOME or MAILING ADDRESS FAX# <br /> 2535 V0 am Drive (209)461-6342 <br /> CITY Stockton STATE CA ZIP 95205 <br /> BILLING ACKNOWLEDGEMENT: 1,the undersigned property or business owner,operator or authorized agent of same, <br /> acknowledge that all site andlor 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 done in accordance with MISAN JOAQUIN <br /> COUYIY Ordinance Codes,Standards,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE,: Qi" DATE: 05/07/2021 <br /> PROPERTYIBUSINESS OWNERO OP£RATDI TANAGER❑ OTHER AUTHORIZED AGENT® Administrative Assistant <br /> IfAPPGICANT is not the Bli txg PARTY proof of althorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION_When applicable,1,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 to the SAN JOAQUIN CouNT-y ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. p <br /> TYPE OF SERVICE REQUESTED: ST- /2TFT;R L c <br /> COMMENTS: <br /> M>4Y 10 <br /> SqN 2021 <br /> t'6AL"04 oti/N <br /> rN p�r0r'4LJNry <br /> ACCEPTED BY: i t U EMPLOYEE#: DATE: 17j- C) <br /> ASSIGNED 10: r .r- EMPLOYEE M DATE: `� U 2l <br /> Date Service Completed (If already completed): SERVICE CODE: P I E: <br /> Fee Amount: `r�o v° Amount Pal TSfc� �� Payment Dale -)71D <br /> Payment Type Invoice# Check# 1 `6 Recol od By: <br /> EHD 48.02-025 SR FORM(Golden Rod) <br /> REVISED 11/1712003 <br /> 1 <br />