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• <br /> * MAY 23 2016 <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> - APoySFYbt` , <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Gas Station FRQ 0030(0 S� b0�►{ga <br /> OWNER/OPERATOR <br /> Chacko Thomas CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> Emil's Liquor <br /> SHEADDRESG (� <br /> 14C§reetNumber Direction California St.street eme ESCalo& 95 2-'e <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number abaci Name <br /> CITY STATE zip <br /> PHONE#1 En. APN# LAND USE APPLICATION# <br /> ( 209) 838-7674 <br /> PHONE#2 Exr. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> Carrie Miller CHECK if BILLING ADDRESS® <br /> BUSINESS NAME PHONE# EXL <br /> Elite IV Contractors 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: 1, the Undersigned property or business owner, operator of authorized agent of sante, <br /> acknowledge that all Site and/or project specific ENVIRONMENTAL HEAL'T'H 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,Stan dard's, 7ATP.and FEDE�RA"L"laws. <br /> APPLICANT'S SIGNATURE: �A I , Ni kk� DATE: <br /> � II�3/I�/6� y <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHERAtIT'HORIZED AGENT'ytJ JLIiPy, //IJfq I(J/,`fj(, <br /> {fAPPL/CANT is not the/11LL/NG PARTY proof of authorization to Sign is required ` Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable,1,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 /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: Install Bravo Dispenser Conversion Frames / UST <br /> COMMENTS: vzo <br /> ' ��a3 ois <br /> ACCEPTED BY: G an 1 O;rY EMPLOYEE DATE: CJ IZ'.t,�yl�1p <br /> ASSIGNED TO: tAlle Q Mianzo 1,• EMPLOYEE#: DATE: I ✓ I Y <br /> Date Service Completed (if already completed): SERVICE CODE: SC l-Ila P I E: 3O <br /> Fee Amount: 43,10 Amount Paid DU Payment Date /�0 <br /> Payment Type ;dw Invoice# C ck# 7/3.1)0 1 Received By: <br /> EHD 45-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />