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SAN JOAQUIN COUNTY ENVIRONMENTAL HEAL T i-i DEPARTMENT <br /> T <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # SERVICE REQUEST # <br /> Retail Fuel irA &XIOA t1 <br /> OWNER / OPERATOR Lubna Hussain CHECK if BILLING ADDRESSF <br /> FACILITY NAME d <br /> BlackHawk . C . <br /> SITE ADDRESS55611 E Waterloo Rd . Stockton 95205 <br /> Street Number Direction I Street Name City Zip 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 ) 913 -2942 <br /> PHONE #Z Exr. BOS DISTRICT LOCATION CODE <br /> ( 408 ) 515 -3380 Sal <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 app is ion and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards, STATE a d FEDERAL laws. <br /> APPLICANT'S SIGNATURE : � ( ( �C 'U2 DATE : ID fig7b <br /> PROPERTY / BUSINESS OWNER ❑ OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT 4eei ` u `�It / , <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 assess ormation <br /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the Same time It is Or <br /> my representative . C N <br /> TYPE OF SERVICE REQUESTED : S r / '` 0J1rV <br /> COMMENTSESP/ <br /> p/ - / / / u �� f , /Cq 2027 <br /> (� L C/ C%'� N� aRv <br /> 4 <���Q0/AI <br /> � COO <br /> � RTMFNT <br /> ACCEPTED BY : jJ EMPLOYEE M DATE : <br /> ASSIGNED TO : V �- � /^1— EMPLOYEE #: DATE: 121 7, <br /> Date Service Completed ( if already completed) . SERVICE CODE: � , 5%p 11 P 1 E:•2:30 -0 <br /> Fee Amount:747q <br /> Ari Amount Pal (.�gPayment Date /S 2 <br /> Payment Type ` �,v Invoice # Check # 70 (023 1 ISI Received By: <br /> EHD 48-02-025 SR FORM (Golden Rod ) <br /> 07/17/08 <br />