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SAN JOAQUIN COUNTY [ NVIRONMENTAL HFAI .LfI i DEPARTMENT <br /> SkRACE REQUEST <br /> Type of Business or Property FACILITY ID # SERVICEREQUEST # <br /> Retail C ' 1 00 0 q`/ <br /> OWNER / OPERATOR <br /> Jessi / Paul Tiwana CHECK if BILLING ADDRESS <br /> FACILITY NAME an ParkwoodsGas & Food <br /> SITE ADD1FT2 W Hammer Lane Stockton 95205 <br /> 1 Street Number Direction Street Name City Zip Code <br /> HOME or MAILING ADDRESS ( If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> WOMEN <br /> PHONE #1 ExT• APN # LAND USE APPLICATION # <br /> ( 209) 888-8156 Tr - Z vk\16 (xvy 11 <br /> PHONE #2 ExT• BOS DISTRICT LOCATION CODE <br /> ( 209) 715-0124 771 C41::U <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR Carrie Miller CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE # ExT. <br /> Elite IV Contractors 2094 461 -6337 <br /> HOME or MAILING ADDRESS 2535 Wigwam Or FAX # <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 or <br /> activity will be billed to me or my business as identified on this form . <br /> also certify that I have prepared this applic tion;� nd that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes , Standards, STA Ed FEDERAL laws. <br /> APPLICANT' S SIGNATURE : (vvv/�,P^ �f IL DATE : 2/24/22 <br /> PROPERTY I BUSINESS OWNER ❑ OPERATOR I MANAGER ❑ OTHER AUTHORIZED AGENT ja Office Manager <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 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 Is provided to me or <br /> my representative . /4Y <br /> TYPE OF SERVICE REQUESTED: NEC <br /> COMMENTS : <br /> SAN ,,o B 2 5 2022 <br /> yEENVIA4NMEC0 Y <br /> ALTy p NTA T <br /> ^EPq RT MENT <br /> ACCEPTED BY : EMPLOYEEM DATE. <br /> ASSIGNED TO: EMPLOYEE M DATE : <br /> Date Service Completed (if already completed: SERVICE CODE: 29� PIE, <br /> Fee Amount : Amount Pal Payment Date 2Z <br /> Payment Type j54� Invoice # Check # 1394SZ/,3 Receiv d By : <br /> EHD 4&02-025 SR FORM (Golden Rod ) <br /> 07/17/08 <br />