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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # SERVICE REQUEST # <br /> Gas & Food Retail A 000 -12 ?1 S U �I 1 ! v <br /> OWNER / OPERATOR <br /> Rupi Padda CHECK If BILLINGADDRESSE] <br /> FACILITY NAME Flag City Arco <br /> SITE ADDRESS 14931 N Flag City Blvd Lodi 95242 <br /> Street Number Direction Street Name 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 #t ExT. APN # LAND USE APPLICATION # <br /> ( ) <br /> PHONE #2 Exr. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> Deborah Jones CHECK if BILLING ADDRESS ® <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 /> 00010, <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 <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 all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards, SJ)TATE and FEDERAL laws. <br /> we I ' <br /> APPLICANT'S SIGNATURE :`. - / F _ Ntl td) DATE: 5/17/2021 <br /> PROPERTY / BUSINESS OWNER ❑ OPERATOR /, ANAGER ❑ OTIIERAUTIIORIZEDAGENT 10 Administrative Assistant <br /> If APPLICANT is not the BILLING PART}: 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 <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 COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at thss me time it is <br /> provided to me or my representative. �-+ Y <br /> TYPE OF SERVICE REQUESTED : fit: C <br /> COMMENTS: <br /> MAY 2 0 ?02 <br /> Sq N JOq <br /> NEq LTH p pq R 7-L T y <br /> E 7- <br /> ACCEPTED BY: EMPLOYEE #: DATE: <br /> � . Zp �20LI <br /> ASSIGNED TO: 1 EMPLOYEE #: DATE: - z. <br /> Date Service Completed (If already completed ) : SERVICE CODE : , q E P 1 E: Q <br /> Fee Amount: 5 v Amount Paid ���� 00 Payment Date szl [ by <br /> Payment Type U'� ,` Invoice # Check # 1 .S�SS I Received By : <br /> EHD 48-02-025 SR FORM (Golden Rod) <br /> REVISED 11 /17/2003 <br />