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RECEIVED <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTHDEPARTMENT JAN 29 2016 <br /> SERVICE REQUEST <br /> Type ofBusinessorProperty FACILITY ID# SERVICEffVOMENT kL <br /> Gas Station M ) C /Z lrst)— TH DEPART ENT <br /> OWNER/OPERATOR <br /> COSICO CHECK IT BILLING AoCRESS <br /> FACILITY NAME Costco#38 <br /> SITEADDRESS 1616 1 E Hammer Lane Stockton 95210 <br /> Street N..G r Diractlon tNama C zipCDCs <br /> HOME at MAILING ADDRESS (N Different from Site Address) <br /> trsaf Numtxr <br /> CITY STATE ZIP <br /> PHONE#1 Eei' APN# LAND USE APPLICATIONP <br /> (209 ) 475-9180 6 I Zs-M I <br /> PHONEY BOB DIG` LOCA iCODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR Carrie Miller CHECK If BILLING ADDRess <br /> BUSINESS NAME PHONE# EXT. <br /> Elite IV Contractors 1 209 461-6337 <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 ENVIRO.NNtENTAL 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: C. DATE 1/29116 <br /> PROPERTY I BUSINESS Ow:NERD OPERATOR/MANAGER D OTDER AU'I'HORIzED AGENT IX Office Manager <br /> If APPLICANT is not the BILLNG PARTI',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 ENVIRDNMENPAL HEALTH DEPARTMENT as soon as it is available and at the sante time it is <br /> provided to me or my representative. <br /> TYPEOF SERVICE REQUESTED: (91)Annular Sensor replacment '�>T ENOIV <br /> q <br /> COMMENTS: <br /> Ai <br /> � OT <br /> ACCEPTED BY: 1 n EMPLOYEE#: DATE: <br /> ASSIGNEOTO: 'Z�r-�� EMPLOYEE$: DATE: /- zq _it <br /> Date Service Completed (N already completed): 1/28/15 SEWCECODE: 1q'Y PIE: <br /> Fee AAmountPajd.OD I <br /> Payment Date z`( �� <br /> Payment Type t�t� Invoice# C ck T F�S Reee Ved By: <br /> END 48-02-025 SR FORM(Golden Rad) <br /> REVISED 11117/2003 <br />