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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 � , 51 `D � &L6 <br /> OWNER / OPERATOR <br /> Swaran Chouhan CHECK if BILLING ADDRESS 13 <br /> FACILITY NAME <br /> K & S Gas & Groceries <br /> SITE ADDRESS 701 E . Dr Martin Luther King Jr Blvd Stockton 95206 <br /> Street Number I Direction I Street Name city de <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> SAME SAME <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE #1 EXT, APN # LAND USE APPLICATION # <br /> ( 209 ) 467-0305 ( Site ) <br /> PHONE #2 EXT. BOS DISTRICT 71 LOCATION CODE <br /> ( 209 ) 993- 1298 Cell <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> Carrie Miller CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE # EXT. <br /> Elite IV Contractors <br /> 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, STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE : DATE : 7/28/2023 <br /> PROPERTY I BUSINESS OWNER ❑ OPERATOR I MANAGER ❑ OTHER AUTHORIZED AGENT E 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 t0 me Or <br /> my representative . <br /> TYPE OF SERVICE REQUESTED , C. { T PAYMENT <br /> COMMENTS : <br /> AUG 0 3 202 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY : EMPLOYEE DATE: / <br /> ASSIGNED TO: �� a EMPLOYEE #: DATE Aaiil 0- / / `Z3 <br /> Date Service Completed (if alread completed) : — SERVICE CODE: G � 2 PIE: ! o <br /> Fee Amount: &v Amount Paid Payment Date 0 f A 22, <br /> Payment Type U ! � Invoice # c c # 66 qo - Received By: / <br /> EHD 48-02-025 SR FORM (Golden Rod) <br /> 07/17/08 <br />