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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID # SERVICE REQUEST # Gas & Food Retail -N-669- fA 0001c� 60 31 ) OWNER / OPERATOR Quik Stop Markets #76 CHECK If BILLING ADDRESSO FACILITY NAME Quik Stop Markets #76 SITE ADDRESS 1030S Olive Avenue Stockton 95205 Street Number DIrectlon Street Name city Zip Code HOME or MAILING ADDRESS ( if Different from Site Address) 302 W Third Street Suite 300 Street Number Street Name CITY Cincinnati STATE OH zIP 45202 PHONE #1 ExT• APN # LAND USE APPLICATION # ( 209 ) 94M731 PHONE #2 EXT, BOS DISTRICTLOCATION CODE ( ) CONTRACTOR / SERVICE REQUESTOR REQUESTOR Deborah Jones CHECK if BILLING ADDRESS BUSINESS NAME PHONE # EXT. Elite IV Contractors ( 209 ) 461 -6337 HOME or MAILING ADDRESS Fax # 2535 Vf wam Drive Stockton , CA 95205 ( 209 ) 461 -6342 CITY Stockton STATE CA ZIP 95205 BILLING ACKNOWLEDGEMENT : I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as identified on this form . 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 COUNTY Ordinance Codes, Standards, STATE and FEDERAL laws. APPLICANT' S SIGNATURE : ejal DATE : 4/22/2021 PROPERTY / BUSINESS OWNER ❑ OPERATORk.N MACER ❑ OTHER AUTHORIZED AGENT ® Administrative Assistant If APPLICANT is not the BILLING PART ,Yproof of atithorization to sign is required Title AUTHORIZATION TO RELEASE INFORMATION : When applicable, 1, the owner or operator of the property located at the above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available PAme time it is provided to me or my representative. % Pr TYPE OF SERVICE REQUESTED: AfWD COMMENTS : 104 (1 2021 SAD V/R QU/N CoU ` I F HEALTH DEpAR M NTY ACCEPTED BY : EMPLOYEE # 6 DATE: 7 ASSIGNED TO : UQ � Qh. EMPLOYEE M DATE : Z Date Service Completed (if already c ' pleted) : SERVICE CODE: ( PIE: 4f Fee Amount : �,VZ 10" b Amount Pai DZ) Payment Date Payment Type Invoice # Check # l Z � Received By : FHT) dR_n9_n9F RR FORM /r;nldan Rnri)