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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 r,41 100022 Z) 2- 5` Co �l012 <br /> OWNER / OPERATOR <br /> Quik Stop Markets , Inc . CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> Quik Sto Markets # 132 <br /> SITE ADDRESS 3555 W Hammer Lane Stockton 95209 <br /> Street Number Direction I Street Name MENNEN MENEEMENCI Zip Code <br /> HOME or MAILING ADDRESS (if Different from Site Address) 165 Flanders Road <br /> Street Number Street Name <br /> CITY Westborough STATE MA ZIP 01581 <br /> PHONE #1 ExT• APN # LAND USE APPLICATION # <br /> ( 508 ) 270- 1400 4469 <br /> PHONE #2 Exr, BOS DISTRICT LOCATION CODE <br /> t ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR CHECKIf 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 /> CITYStockton 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, STATE and FEDERAL laws. <br /> APPLICANT' S SIGNATURE DATE : 5/06/2021 <br /> PROPERTY / BUSINESS OWNER ❑ OPERA / MANAGER ❑ OTHER AUTHORIZED AGENT ® Administrative Assistant <br /> IfAPPLICANT is not the BILLIN ARTY, proof of auNtorization 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 env�'Itaq <br /> �ntal/site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is availa7TaCt �aa time it is <br /> provided to me or my representative . A C C ` � <br /> TYPE OF SERVICE REQUESTED: / "y-'/ / U A <br /> COMMENTS: ON <br /> jROQCJ/N CO2, <br /> Tye p � <br /> q�� o�� � <br /> ACCEPTED BY: EMPLOYEE #: DATE: <br /> ASSIGNED TO: t7 EMPLOYEE #: DATE: <br /> Date Service Completed (if already completed) : SERVICE CODE : P 1E* <br /> Fee Amount: t7 Amount Pai OD Payment Date $ <br /> Payment Type , Invoice # Check # Z Rece ed By : <br /> EHD 48-02-025 SR FORM (Golden Rod) <br /> REVISED 11 /17/2003 <br />