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SAN ClAOUIN COUNTY ENVIRONMENTAL - T I I DEPARTMENT <br /> x) 11 4V CE REQ != Slf <br /> Type of Business or Property FACILI'T' Y 11) 11 SERVICE REQUEST # <br /> /f000 (a 7 0 �� � � ��- <br /> Retail Fuel "* � <br /> OWNER / OPERATOR FG AmerciaI�I <br /> CHECK if BILLING ADDRESSl4 � <br /> FACILITY NAME Quik Stop # 148 <br /> SITE ADDRESS r W Lockeford St . Lodi 95240 <br /> 20JStreel Number Direction Street Name City Zip Code <br /> HOME or MAILING ADDRESS ( If Different from Site Address) 165 Flanders Road <br /> Street Number Street Name <br /> CITY Westborough STATE ZIP01581 <br /> MA <br /> PHONE #1 EXT. API LAND USE APPLICATION # <br /> ( 508 ) 270 -4444 <br /> PHONE #2 EXT. BOS DISTRICT LOCATION CODE <br /> ( 209 ) 369- 1142 <br /> CONTRACTOR SERVICE RE' QUESTO R <br /> REQUESTOR Carrie Miller CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE # EXT. <br /> Elite IV Contractors 2091 461 -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 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 : Cbz DATE : 6/ 16/2022 C <br /> i <br /> PROPERTY I BUSINESS OWNER ❑ OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT ® Office Manager <br /> If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required Tlrrc <br /> AUTHORIZATION TO RELEASE INFORMATION : When applicable , 1 , 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 j <br /> my representative . <br /> TYPE OF SERVICE REQUESTED : 1 J � C <br /> COMMENTS : �� <br /> qN �N <br /> 8 <br /> �FALTy Qu//v MFNTOqU� i' y j <br /> 4RT <br /> EMPLOYEE # : DATE : <br /> ACCEPTED BY : v <br /> ASSIGNED TO : _ EMPLOYEE # : DATE : <br /> Date Service Completed ( if already completed ) : (p GJ 2 Z SERVICE CODE : PIE* <br /> Fee Amount : / G 2C) 0 Amount Paid/F 16; dd Payment Date <br /> Payment Type ; - Invoice # Check # III JC <br /> TS �L'� Received By : i <br /> I <br /> EHD 0 `� 'J` <br /> 2 -025 51 I DD ov4 �� I /�' ' �` SR FORM ( Golden Rod ) <br /> I07/17//00 8 r <br />