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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 FArcVa2q 1 ire <br /> OWNER / OPERATOR <br /> VandePol Petroleum CHECK if BILLING ADDRESS <br /> FACILITY NAME Ripon CFN <br /> SITEADDRESS 816 S Frontage Rd Ripon 95366 <br /> Street Number Direction I 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 STAATE 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 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 /> I 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 : (?.a DATE : 3/6/2023 <br /> PROPERTY i BUSINESS OWNER ❑ OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT ® Office Manager <br /> IfAPPLIcANT 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 t0 me or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED : g1 <br /> COMMENTS : 0 <br /> ACCEPTED BY : EMPLOYEE #: DATE: <br /> ASSIGNED TO : I" 1 EMPLOYEE #: e DATE: <br /> Date Service Completed (if already completed) : SERVICE CODE: PI E: �f� �? <br /> Fee Amount: &0 Ems' Amount Paid Payment Date 4 <br /> Payment Type Invoice # Check # Received By: <br /> EHD 48-02-025 SR FORM (Golden Rod) <br /> 07/17/08 <br />