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SAN .JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />ADDRESS <br />FACILITY ID # <br />SERVICE REQUEST. # <br />B SINESS NAME <br />A. g�K t E-OAI l -W - <br />SAN JOAQUIN COU <br />PHONE# ExT' <br />?r 3r$ - o3 <br />HOME or MAILING ADDRESS <br />I a 31" <br />Retail fuel and c -store <br />E- ktc sT <br />FA0012659 <br />m) - vv// <br />5 fz '6 <br />OWNER / OPERATOR <br />ASSIGNED TO: V <br />EMPLOYEE #: <br />DATE: <br />Date Service Completed (if already completed): <br />CHECK If BILLING ADDRESS <br />Love's Travel Stops of California <br />P/E: �o <br />FACILITY NAME <br />Amount Paid '3"1S <br />Payment Date <br />Love's Travel St o #223 <br />Payment Type <br />-T <br />SITE ADDRESS <br />Received By <br />1553 Street Number <br />Direction <br />Colony Rd <br />Street Name <br />Ripon <br />c1tv <br />95366 <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />PO Box 26210 <br />Street Number <br />Street Name <br />CITY <br />STATE ZIP <br />Oklahoma CitV <br />OK 73126 <br />PHONE #1 ExT• <br />APN # <br />LAND USE APPLICATION # <br />( 209) 599-0740 <br />Z4 S- 3L/o -7 q <br />PHONE #2 ExT• <br />BOS DISTRICT Y�I <br />LOCATION COVE <br />CONTRACTOR/ SERVICE REQUESTOR <br />REQUESTOR <br />ADDRESS <br />WeIrp `�� <br />CHECK If BILLING <br />B SINESS NAME <br />A. g�K t E-OAI l -W - <br />SAN JOAQUIN COU <br />PHONE# ExT' <br />?r 3r$ - o3 <br />HOME or MAILING ADDRESS <br />ENVIROMENTAL <br />FAX# <br />E- ktc sT <br />HEALTH DEPARTM <br />m) - vv// <br />CITY 0.4 <br />STATE I✓ ZIP 0411 <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: 0 DATE: 03/01/14 <br />PROPERTY / BUSINESS OWNER ❑ OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT ie Env Divisions Mgr <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 />t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon a5 it IS available and at the Same time It IS provided t0 me Or <br />my representative. P AA NT <br />TYPE OF SERVICE REQUESTED: tk `, T 4-a I"1w 6 -1- RECEIVEd <br />COMMENTS: <br />MAR 14 2014 <br />SAN JOAQUIN COU <br />ENVIROMENTAL <br />HEALTH DEPARTM <br />ACCEPTED BY:4. <br />EMPLOYEE #: <br />DATE: 7 4 <br />7 <br />ASSIGNED TO: V <br />EMPLOYEE #: <br />DATE: <br />Date Service Completed (if already completed): <br />SERVICE CODE: I i� <br />P/E: �o <br />Fee Amount: -5-1 7 <br />Amount Paid '3"1S <br />Payment Date <br />3A kA <br />Payment Type <br />Invoice # <br />Check # ZS <br />Received By <br />EHD 48-02-025 SR FORM (Golden Rod) <br />07/17/08 <br />N <br />T <br />