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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />Type of Business or Property <br />CONTRA(C'If'®R / SERVICICi <br />Carrie Miller <br />FACILITY ID 4 <br />SERVICE REQUEST # <br />BUSINESS NAME <br />Elite IV Contractors <br />® 2021 <br />PHONE# <br />ExT• <br />Gas & Food Retail <br />FA0002570 <br />209461 <br />-6337 <br />OWNER / OPERATOR <br />ADDRESS <br />2535 Wigwam Dr <br />Cumberland Farms / EG <br />America <br />CHEC/(IfBILLING ADDRESS <br />FACILITY NAME Quik Stop 144 <br />( <br />SITE ADDRESS272Stockton <br />CITY <br />West <br />Lane <br />Zip 95205 <br />DATE: J <br />1h4 <br />95210 <br />Street Number <br />Direction <br />St eet Name <br />City <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />SERVICE CODE: /L�0-��� <br />W, <br />Thrid Street <br />302 <br />Street Number <br />Street Name <br />CITY Cincinnati <br />0S,T(\TE Zip 45202 <br />PHONE #1 EXT1- <br />ApN # <br />— — -- _ <br />LAND USE APPLICATION* <br />( 200 952-8812 <br />Invoice # <br />Check # c.L ` <br />PHONE #2 ExT. <br />( ) <br />Received <br />BOS DISTRICT <br />LOCATION CODE <br />I3EQLTESTOI2 <br />REQUESTOR <br />BILLING ACKNOWLEDGEMENT: I, the undersigned propert <br />Carrie Miller <br />CHECK If BILLING ADDRESS <br />BUSINESS NAME <br />Elite IV Contractors <br />® 2021 <br />PHONE# <br />ExT• <br />SAN <br />t EN �RONI�CONNT <br />209461 <br />-6337 <br />HOME or MAILING <br />ADDRESS <br />2535 Wigwam Dr <br />FAC # <br />209 <br />461-63642 <br />EMPLOYEE M <br />( <br />CITY <br />Stockton <br />STATECA <br />Zip 95205 <br />y or business owner, operator or authorized agent of same, <br />acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hOUlly Charges associated Wlth this project or <br />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, STffk,end FEDERAL laws. <br />^ <br />APPLICANT'S SIGNATURE: ( Gt?/1iUC 11/16 <br />I. DATE: 11/24/2021 <br />PROPERTY /BUSINESS OWNER ❑ OPERATOR/ MANAGER <br />❑ OTHER AUTHORIZED AGENT B Office Manager <br />it 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 above <br />site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information <br />t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the same time It4 O me or <br />my representative. l� � ie ' ]' <br />TYPE OF SERVICE REQUESTED: r: L) <br />EHD 48-02-025 SR FORM (Golden Rod) <br />07/17/08 <br />COMMENTS: „/ n / a n � <br />(itL�C� <br />S�/�s <br />® 2021 <br />SAN <br />t EN �RONI�CONNT <br />HEALTH <br />ENTAL <br />DL. <br />PPARTNIENT <br />ACCEPTED BY: �y /T ✓7 <br />EMPLOYEE M <br />DATE: <br />ASSIGNED TO: ,� <br />EMPLOYEE M <br />DATE: J <br />1h4 <br />Ll <br />Date Service Completed (if already completed): ,::� <br />SERVICE CODE: /L�0-��� <br />PIE�g60 <br />Fee Amount:`' <br />Amount Paid <br />1�� ( <br />Payment Date <br />Payment Type <br />Invoice # <br />Check # c.L ` <br />Tg� <br />Received <br />By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />07/17/08 <br />