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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # SERVICE REQUEST # <br /> nn ✓I � <br /> Gas & Food Retail �V <br /> OWNER / OPERATOR <br /> Rupi Padda CHECK If BILLING ADDRESS <br /> FACILITY NAME BAI Petro Inc / Flag City Arco <br /> SITE ADDRESS 14931 1 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 #1 EXT. APN # LAND USE APPLICATION # <br /> ( 209 ) 366 - 1414 <br /> PHONE #2 EXT• BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK if BILLING ADDRESS <br /> Deborah Jones <br /> BUSINESS NAME PHONE # EXT. <br /> Elite IV Contractors 209 461 -6337 <br /> HOME Or MAILING ADDRESS FAX # <br /> 2535 Wigwam 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 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, STATE and FEDERAL laws. <br /> APPLICANT' S SIGNATUR DATE : 6/07/2021 <br /> PROPERTY / BUSINESS OWNER ❑ OPERATORM NAGER ❑ OTHER AUTHORIZED AGENT ® Administrative 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 <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 HEALTIi DEPARTMENT as soon as it is available and at ffiP) e_ ne it is <br /> provided to me or my representative. f��t rMEF wr <br /> TYPE OF SERVICE REQUESTED: S 1I 2E <br /> COMMENTS : IY 0 0�� <br /> i SAN ,IpgQUIN <br /> HEgLrH pE AE M�OUN Y <br /> r <br /> ACCEPTED BY: � �J y EMPLOYEE #: DATE : <br /> ASSIGNED TO : ���r vvvv���� EMPLOYEE #; DATE : 4 (�jJ <br /> Date Service Completed (if already complete / SERVICE CODE: q 2% � P I Ev ;?' <br /> Fee Amount : U Amount Paid ZZ � � � Payment Date �1 <br /> Payment Type Invoice # Check # Zros" 2-ZZ-2 , Rece ed By . <br /> EHD 48-02-025 SR FORM (Golden Rod) <br /> REVISED 11 /17/2003 <br />