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L►..�a�irr��W��1g���-- <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL 116fi?rk�I3P°IUTTMENT <br /> SERVICE REQUEST "'e - <br /> Type of Business or Property FACILITY It# SERVICE REQUEST# <br /> Gas Station Mini Mart F I+CU L c, -7 � 7 Cj 1 <br /> OWNER/OPERATOR <br /> Ran'eetSingh CHECK ITBILLING ADORESSO <br /> FACILITY NAME Arco AM/PM <br /> SITE ADDRESS 1340 Colony Rd Ripon 95366 <br /> Street Number I Direction I Street Name Clty Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number street Name <br /> CITY STATE ZIP <br /> PHGNE#1 Exr. APN# LAND USE APPLICATION <br /> (209) 599-7600 <br /> PHONE En. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR Megan Mitchell CHECK N BILLING ADDRESS® <br /> BUSINESS NAME Elite IV Contractors PHONE# SIT_ <br /> 461-6337 <br /> HOME or MAILING ADDRESS Elite IV Contractors FAX# <br /> ( 209) 461-6342 <br /> CITY Stockton STATE Ca ZIP 95205 <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 and FEDERAL flaws. � �/�/ <br /> APPLICANT'S SIGNATURE: /ie¢¢Cd ' /�ee',�.C!!,¢GG DATE: <br /> 9/14/2016 <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT M Office Assistant <br /> IjAPPLICANT is not the BILLING PAR proof ojauthorization to sign is required rice <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 CIS Soon as it is available and� 'Y I i <br /> wee' <br /> FiS <br /> provided to me or my representative. �tw <br /> TYPE OFSERvICEREQUESTED: RepairFill Sum s - Started on SR#70287 / SR#73701 VCU <br /> COMMENTS: SEP 'Lilb <br /> SAN JOAQUIN COUNT <br /> ENVIROMENTgL <br /> HEALTH DEP <br /> ARTMEN <br /> ACCEPTED BY: �''- -�,Z1 EMPLOYEE M DATE: q. l /-/ <br /> ASSIGNED TO: ,'p .. EMPLOYEE M DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: �1 <br /> Fee Amount: ,..+ 1 -7 — Amount Paid ,�[/./'7 Payment Date '1//S// !P <br /> Payment Type M I SCI /IIn�voiilce# ,I Check#t Received By: �. <br /> EHD 48-02-025 v" '1 7' I�3 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />