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SAN JOA (ILIiN Q OLJNTY ENV16dOR11VIU1\fi'AL Fni DEPARTMENT <br /> 9 <br /> � ERVIGE R E C UE (3 <br /> Type of Business or Property FACILITY IU I/ ( EdaVICE REQUEST # <br /> R <br /> Retail Fuel A000P2 �-' IN <br /> OWNER / OPERATOR <br /> Thien Phan CHECK if BILLING ADDRESS <br /> FACILITY NAME California Stop <br /> SITE ADD ESS Stockton <br /> 224 Manthey Road 95206 <br /> Street Number Direction Street Name Cil Zi 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 ) 462-7621 <br /> PHONE #2 EXT. BOS DISTRICT LOCATION CODE <br /> ( 209 ) 406- 1484 <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> Carrie Miller CHECK if BILLING ADDRESS <br /> BUSINESS NAME Elite IV Contractors PHONE # EXT. <br /> 20 %4611 -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, STATE and FEDERAL laws . <br /> APPLICANT' S SIGNATURE : DATE : 6/ 13/2023 <br /> PROPERTY / BUSINESS OWNER ❑ OPERATOR I MANAGER ❑ OTHER AUTHORIZED AGENT IJ Office Manager <br /> If APPLICANT is not the BILLING PARTY. proof of authorization to sign Is required Tule <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 : u� / PAYMENT <br /> COMMENTS: RECEIVED <br /> /ia.�,.) V�s � <br /> C JUN 15 202 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY : —y1 �� EMPLOYEE M DATE : (4 <br /> ASSIGNED TO : G- I EMPLOYEE M DATE : <br /> Date Service Completed (if already completed ) : SERVICE CODE: P I E: <br /> Fee Amount: �j �' - Amount Paid Payment Date oZA <br /> Payment Type t�5 � Invoice # Ct�ecic # 3 -�-�2, Received By: <br /> EHD 4&02-025 SR FORM (Golden Rod ) <br /> 07/17/08 <br />