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SAN JOAQU OUNTY ENVIRONMENTAL HEALTAPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Gas Station tib 7 __J j��7aZ <br /> OWNER/OPERATOR <br /> Rinku Singh CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> Charter Way Chevron <br /> SITE ADDRESS 508W Charter Way Stockton 95205 <br /> Street Number ton I ame city Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> ( 209) 992-1735 <br /> PHONE#2 En. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR - <br /> Carrie Miller I CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <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: 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 <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 laws. <br /> APPLICANT'S SIGNATURE: DATE; 7/24/15 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT 13 Office Mamnger <br /> /f 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 /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: Drop Tube 67 Tank#1 A,q} <br /> COMMENTS: ✓ ��` N2• <br /> ACCEPTED BY: ry EMPLOYEE#: DATE: -7 a <br /> ASSIGNED TO: ' EMPLOYEE#: DATE: 7 <br /> Date Service Completed (If already completeal: SERVICE CODE: I q$ P I E:23p8 <br /> Fee Amount: fM©. 1 Amount Pai �9b �� Payment Date WE� <br /> Payment Type G Invoice# Ch # Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />