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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 ( fn48B <br /> OWNER / OPERATOR <br /> VandePol Petroleum CHECK If BILLING ADDRESS 13 <br /> FACILITY NAME Ripon CFN <br /> SITE ADDRESS 816 FrontageFrontage Rd Ripon 95366 <br /> Street NumberFDSIr7ectlon Street Name City Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> PO Box 1107 Street Number Street Name <br /> CITY Stockton STnATE ZIP 95201 <br /> PHONE #1 EXT. APN # LAND USE APPLICATION # <br /> (209 ) (209 ) 465-3421 <br /> PHONE #2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> Carrie Miller CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE # EXT. <br /> Elite IV Contractors 209 ) 461 -6337 <br /> HOME or MAILING ADDRESS FAx # <br /> 2535 Wigwam Dr (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,/s, STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE : (�a44Z4 Nd&- DATE : 3/6/2023 <br /> PROPERTY / BUSINESS OWNER ❑ OPERATOR I MANAGER ❑ OTHER AUTHORIZED AGENT 0 Office Manager <br /> mpiIf APPLICANT is not the BILLING PARTY. proof of authorization to Sign Is required Ti �vC�D <br /> AUTHORIZATION TO RELEASE INFORMATION : When applicable , I , the owner or operator of the property located at 1he above <br /> site address , hereby authorize the release of any and all results, geotechnical data and/or environmental/site asslnl ion <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. SAN JOAQUIN COW" <br /> migoNMENTAIL' <br /> HEALTH DEPART <br /> TYPE OF SERVICE REQUESTED : <br /> s ' <br /> oet try <br /> COMMENTS : <br /> ACCEPTED BY : EMPLOYEE # : DATE; 2 <br /> ASSIGNED TO : '/) EMPLOYEE M DATE : <br /> Date Service Completed (if already completed) : — SERVICE CODE: f � w4f P I E• �Z:': >o aI <br /> Fee Amount: �� Amount Paid g / Payment Date la ' a3 <br /> Payment Type v l `) Invoice # # 3�-� Received By: <br /> EHD 48-02-025 SR FORM (Golden Rod) <br /> 07/17/08 <br />