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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # SERVICE REQUEST # <br /> Retail Fuel F/ voo 2/ p sT�-(f j 2 � LF <br /> OWNER / OPERATOR <br /> Roger Howell CHECK If BILLING ADDRESS ® <br /> FACILITY NAME Loves <br /> SITEADDRE1 %250 N Thornton Road Lodi 95242 <br /> Street Number Direction Street Name Cit <br /> Zip Code <br /> HOME or MAILING ADDRESS ( If Different from Site Address) <br /> Same <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE #1 EXT. APN # LAND USE APPLICATION # <br /> ( 209) 333-9392 <br /> PHONE #2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR Carrie Miller CHECK If BILLING ADDRESS <br /> BUSINESS NAMEPHONE # EXT• <br /> Elite IV Contractors <br /> 209 61 -6337 <br /> HOME or MAILING ADDRESS 2535 Wigwam Dr FAx # <br /> ( 209)461 -6342 <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 appli tion nd that the work to be performed will be done in accordance with all SAN JOAQUIN la <br /> COUNTY Ordinance Codes , Standards, STA and F DERAL ws . <br /> APPLICANT'S SIGNATURE : /� L (_„ ✓ �( /6�) DATE , 4/29/2022 <br /> PROPERTY / BUSINESS OWNER ❑ OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT 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 It IS provided t0 me Or <br /> my representative . <br /> TYPE OF SERVICE REQUESTED : <br /> COMMENTS : <br /> SgNJ0,4 Mgy0 <br /> QU11V CO HE,q�W��� UNTY <br /> ACCEPTED BY : , ` EMPLOYEE M DATE : Aga <br /> ASSIGNED T0 : , v '7 G� EMPLOYEE #: DATE : �/Z i <br /> Date Service Completed (if already completed) : SERVICE CGDE : Ie761 _ 2 PIE : <br /> � 61 � c3lJ 3 <br /> Fee Amount: � ozAmount Pal UD Payment Date S3 <br /> Payment Type j � Invoice # Check # � �Z� D�� Received By : <br /> EHD 48-02-025 SR FORM ( Golden Rod ) <br /> 07/17/08 <br />