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• RECEIVED <br /> DEC 16 2015 <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST ENVIRONMENTAL <br /> Type of Business or Property NT <br /> FACILITY ID# SERVICE REQUEST# <br /> Gas Station Min Mart V <br /> OWNER/OPERATOR <br /> Rupi and Bill CHECK N BILLING ADDRESS <br /> FAciuw NAME <br /> Georges Mini Mart <br /> SHE ADDRESSt 6662 Highway 88 Lockford 95240 <br /> SIM M1 Na— CH <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Sheet NumberStre,t NMO <br /> CITY STATE ZIP <br /> PHONE#1 Err' APN# LAND USE APPLICATION# <br /> (209 ) 334-3233 <br /> PHONE 92 En- BOS DISTRICT LOCATION CODE <br /> ( 1 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REDUESTOR Carrie Miller CHECK If BILLING ADDRESS® <br /> BUSINESS NAME PHONE# Err. <br /> Elite IV Contractors I 209l 461-6337 <br /> HOME or MAILING ADDRESS 2535 Wigwam Dr. FAX# <br /> (209 ) 461.6342 <br /> CITY Stockton STATE LP <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 ENVIRONMEN'I'AL HF,ALTIi 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 JOAQ11IN <br /> COUN'T'Y Ordinance Codes,Standards re:and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: _4y�Lg RA DATE: 12/16/15 <br /> PROPE.R7V/BUSINESS Ow:NERD OPERA'T'OR/MANAGER ❑ OTHER AUTHORIZED AGENT IR Office Manager <br /> If APPLICANT is not the BILLING PAR rr proof of authorization to.sign is required rule <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 te time It is <br /> provided to me or my representative. ry� <br /> TYPE OF SERVICE REQUESTED: Replaced 67 LD Limit �� <br /> COMMENTS: '10 ,1 <br /> IkAtr4o0�/cT U/ti <br /> 4,9 <br /> rk <br /> T�FNT <br /> ACCEPTED BY: EMPLOYEE#: DATE: 14 1S <br /> ASSIGNEDTO: S N�G EMPLOYEES: DATE: 12 11 15 <br /> Date Service Completed (If already completed): 12/15/15 SERVICE CODE: SC/Iq e" I P"; <br /> E: <br /> Fee Amount: Q-VU Amount Pa 390. Payment Date l7 fS <br /> Payment Type / Invoice# Ck# 5��3 Received By: <br /> EHD 43-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />