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SAN JOAQL 4. OUNTY ENVIRONMENTAL HEALTi EPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />SERVICE REQUEST # <br />GAS STATION <br />CHECK if BILLING ADDRESS <br />LUCY S I LVAS - THOMAS <br />0 9 3 -75 <br />I� <br />OWNER / OPERATOR <br />BUSINESS NAME <br />CHEVRON <br />CHECK if BILLING ADDRESS <br />FACILITY NAME <br />TOWN & COUNTRY CONTRACTORS, INC <br />CHEVRON GAS <br />n <br />ENVIRNNMEN HEALT*c°�P <br />SITE ADDRESS <br />HOME or MAILING ADDRESS <br />FAX # <br />ACCEPTED BY: --- <br />3181 LUYUNG DRIVE STE A <br />10858 <br />I <br />TRINITY PR®reetName <br />9aNCHO CORDOVA <br />STOCKTOT& <br />952zi9Code <br />Street Number <br />Direction <br />SERVICE CODE: / CIt <br />P IE: 230i <br />Fee Amount: # 3 q,,5' <br />i5 <br />HOME Or MAILING ADDRESS (If Different from Site Address) <br />Payment Date 2 (e) ( b <br />Payment Type7-1 <br />Street Number7 <br />Check # 1 3 b 3 <br />Street Name <br />CITY <br />STATE ZIP <br />PHONE #1 ExT• <br />APN # <br />LAND USE APPLICATION # <br />1209-P52-2213 <br />06602015 <br />PHONE #2 ExT• <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />CHECK if BILLING ADDRESS <br />LUCY S I LVAS - THOMAS <br />BUSINESS NAME <br />PHONE# <br />ExT. <br />TOWN & COUNTRY CONTRACTORS, INC <br />n <br />ENVIRNNMEN HEALT*c°�P <br />916 636-9500 <br />HOME or MAILING ADDRESS <br />FAX # <br />ACCEPTED BY: --- <br />3181 LUYUNG DRIVE STE A <br />DATE: <br />( ) <br />916-636-9507 <br />9aNCHO CORDOVA <br />STATECA <br />ZIP95742 <br />BILLING ACKNOWLEDGEMENT: 1, 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 <br />or 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 a d FEDERAL laws. �I <br />APPLICANT'S SIGNAT <br />_ D,aTE• <br />PROPERTY/ BUSINESS OWNER❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT ® CONTRACTOR <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 <br />above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br />information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br />,;A A r., v,rr'v <br />Fxv— w w .,.., v..,.y I.F' ,o....v... <br />TYPE OF SERVICE REQUESTED: <br />COMMENTS: <br />FEB 1 91�101g1� 1 <br />n <br />ENVIRNNMEN HEALT*c°�P <br />PERMIT,ISERM <br />ACCEPTED BY: --- <br />EMPLOYEE #: ��C <br />DATE: <br />4 <br />ASSIGNED TO: ro 6i r C1. 0,5 <br />EMPLOYEE #: <br />DATE: <br />Date Service Completed (if already completed): <br />SERVICE CODE: / CIt <br />P IE: 230i <br />Fee Amount: # 3 q,,5' <br />i5 <br />Amount Paid 316 _ <br />Payment Date 2 (e) ( b <br />Payment Type7-1 <br />Invoice # <br />Check # 1 3 b 3 <br />Received By: �_ <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />