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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 ryo J IQml <br /> U <br /> OWNER / OPERATOR <br /> Quik St0 Markets # 144 CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> Quik Stop Markets # 144 <br /> SITE ADDRESS 7272 West Lane Stockton 95210 <br /> Street Number DI ctlon Street Name city Zip Code <br /> HOME Or MAILING ADDRESS (if Different from Site Address) 302 W Third Street Ste 300 <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> Cincinnati OH 45202 <br /> PHONE #1 EXT• APN # LAND USE APPLICATION # <br /> ( 209 ) 952-8812 <br /> PHONE #2 EXT• BOS DISTRICTLOCATION CODE <br /> ( ) <br /> 11 <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 Wigwam Drive Stockton , CA 95205 ( ) <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, STATE and FEDERAL laws. <br /> APPLICANT' S SIGNATURE;�Vdv DAT l 4/21 /2021 <br /> PROPERTY / BUSINESS OIVNER ❑ OPERAT / MANAGER ❑ 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. HEALTH DEPARTMENT as soon as it is available an" a time it is <br /> provided to me or my representative. ENWr <br /> TYPE OF SERVICE REQUESTED: ,S ED <br /> COMMENTS: SqN G 2021 <br /> LO <br /> " HEALTH pO PMEnCO LNTy <br /> ARTMENT <br /> ACCEPTED BY : ` V EMPLOYEE #: DATE : H <br /> ASSIGNED TO : � N p ( EMPLOYEE #: DATE: ` 7 <br /> Date Service Completed (if already comple ed) : ,.�_ SERVICE CODE: J P / E: <br /> Fee Amount: (� Amount Paid OD Payment Date <br /> Payment Type 5'< � Invoice # Check # 6 Recei ed By : 142 <br /> EHD 4&02-025 SR FORM (Golden Rod ) <br /> REVISED 11 /17/2003 <br />