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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 gr, <br /> OWNER I OPERATOR Jessie Singh CHECK if BILLING ADDRESS <br /> FACILITY NAME Manteca Gas N Food <br /> SITE ADDRESS E 1151 Louise Ave <br /> Street Number [DirectionManteca <br /> 1229 95336 <br /> Street Number Street Name Cft Zi Code <br /> HOME Or MAILING ADDRESS ( If Different from Site Address) <br /> SAME Street Number Street Name <br /> CITY STATE zip <br /> PHONE #1 EXT, APN # LAND USE APPLICATION # <br /> (209 ) 239-2233 <br /> PHONE #2 EXT. BOS DISTRICTLOCATION CODE <br /> ( 209) 814-3730 <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR Carrie Miller CHECK if BILLING ADDRESS <br /> BUSINESS NAME Elite IV Contractors PHONE # EXT, <br /> ( 20 %461 -6337 <br /> HOME or MAILING ADDRESS 2535 Wigwam Dr FAx # <br /> ( ) <br /> CITY Stockton STATE CA ZIP 9505 <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 tome or my busines a identified on this form . <br /> also certify that I have prepared this pplic Zion and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes , StandardS STATE nd FEDERAL law . / <br /> APPLICANT' S SIGNATURE : tlw- /( 011E DATE : 4/22/2022 <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 /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is provided to me or <br /> my representative . <br /> TYPE OF SERVICE REQUESTED : <br /> COMMENTS : D R� <br /> SqN MM o <br /> Jd <br /> N /poivy�C j>n,., <br /> N� tr/R l� NT'q I Y <br /> q O1 A d <br /> ACCEPTED BY : T v EMPLOYEE #: DATE : E <br /> ASSIGNED TO : n /� � EMPLOYEE # : DATE : N . JX� <br /> Data Service Completed ( If already Completed) : SERVICE CODE: �O �/� PIE : �_�-�� <br /> Fee Amount: Pvit�5& emo Amount Paid7l �SPayment Date <br /> Payment Type ` � Invoice # Check # /4p 47SReceived By : <br /> EHD 48-02-025 SR FORM ( Golden Rod ) <br /> 07/17/08 <br />