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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST qt <br /> t <br /> Type of Business or Property FACILITY ID It SERVICE EQUEST # <br /> Retail Fuel A <br /> OWNER / OPERATOR <br /> Vikas Patel CHECK If BILLING ADDRESS <br /> FACILITYNAME West Valley Auto Service <br /> SITEADDRE$$615 W Grant Line Rd Tracy 95304 <br /> G Street Number Direction Street Name Cit Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Same as above Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE #1 ExT• APN # LAND USE APPLICATION # <br /> 415 ) 572m4837 Cell <br /> PHONE #2 ExT• BOS DISTRICT LOCATION CODE <br /> ( 209) 836-3434 <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR Carrie Miller <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE # ExT' <br /> Elite IV Contarctors 209 61 -6337 <br /> HOME or MAILING ADDRESS FAx # <br /> 2535 Wi wain 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 : DATE : 4/10/2024 <br /> PROPERTY / BUSINESS OWNER ❑ OPERATOR I MANAGER ❑ OTHER AUTHORIZED AGENT Office Manager <br /> If APPLICANT IS not the BILLING PARTY, proof Of authorization t0 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 a5 soon as it is available and at the Same time It IS provided t0 me Or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: ID F <br /> ACCEPTED BY: EMPLOYEE #: DATE: ( Q Z <br /> ASSIGNED TO : w EMPLOYEE #: DATE: 2 <br /> Date Service Completed (if already completed) : - SERVICE CODE : <br /> Fee Amount: .' C} , VV Amount Paid Payment Date <br /> Payment Type Invoice # Check # Received By : <br /> EHD 48-02-025 5R FORM (Golden Rod) <br /> 07/17/08 <br />