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`i 1.00 <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Gas Station Min Mart `:w- <br /> OWNER/OPERATOR <br /> Jazz Enterprises CHECK If BILLING ADORES$❑ <br /> FACILITY NAME <br /> Woodbridge Arco <br /> SITE 189703 i �0 C, VV Lower Sacramento Stockton 95258 <br /> 1897 Stria Nu.ber I Direct on Street Name Citv ZI Code <br /> HOME Or MAILING ADDRESS (if Different from Site Address) <br /> Street Number Sveet Name <br /> CITY STATE ZIP <br /> PHONE#1 Em APN# LAND USE APPLICATION# <br /> (209 ) 339-8238 r (� <br /> PHONE#2 Exr• BIDS DISTRICT LOCATION CODE <br /> ( ) �Qq 7q <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> Carne Miller CNELK N BILLING ADDRESS <br /> BUSINESS NAME Elite IV Contractors PHONE# Ear. <br /> ( 911Q 1 41,1-6337 <br /> HOME Or MAILING ADDRESS FAX# <br /> 2535 Wigwam Dr <br /> ( 209 ) 461-6342 <br /> CITY Stockton STATE CA LP 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 fort. <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 JOAQIIIN <br /> COUNTY Ordinance Codes,Standards,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: (a2A,te:._ JA..[' A, DATE: 214/16 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OrRERAUTNOIUMDAGENTID OfficeManager <br /> IJAPpLimVT is Hot the BlJLLM PARTY.proof of authorization to sign is required Titre <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 JOAQLT N COUNTY ENVIRONMENTAL HEALTII DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. PAYS IT-�i�(^�i. <br /> TYPE OF SERVICE REQUESTED: RC laced 91 product Leak Detector CFN E I <br /> COMMENTS: 0� eJ/Jy FEB 0 4 2 116 <br /> F �V� <br /> °ems ENVIRON NT <br /> N=p,Tl.,nrnga AL <br /> ACCEPTED BY: EMPLOYEE#: DATE: O Z- D C _' <br /> 10 <br /> ASSIGNED TO: O� EMPLOYEE#: DATE: (SZ_p-2� . /to <br /> Date Service Completed (If already completed): 2/3/16 SERVICE CODE: I C1 PIE: 2 W g <br /> Fee Amount -�!)Vl0 OU Amount PalU!0 l]CJ Payment Date <br /> Payment Type Vj6,9, — Invoice# C • X37 Reee ed By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />