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SAN "170"MkftLONMENTAL HEALTISPARTMENT <br /> APR 01 L%RVICE REQUEST <br /> Te of Business or Property FACILITY ID# SERVICE REQUEST# <br /> (as Station ENVIRONMENT L �� o«, s� ��I 00 '7 1 � A, <br /> uG tTuncc <br /> OWNER/OPERATOR Jivtesh Gill CHECK If BILLING ADDRESS❑ <br /> FACUTYNAME Arch Arco AMPM <br /> SITE,AgUgEss S HWY 99 Stockton 95215 <br /> 4ttbb Street Number Direction Street Name 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) 948-2438 ' p S <br /> PHONE#2 Ex . BOS DISTRICT LOCATION fODE <br /> I ) 9 6A <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR Kim White CHECK If BILLING ADDRESS❑ <br /> BUSINESS NAME Elite IV Contractors PHONE# Ez. <br /> 209 461-6337 <br /> HOME or MAILING ADDRESS Wigwam Dr. FA%# 461-6342 <br /> ( 209) <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 /> 1 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: 4/1/2015 <br /> PROPERTY/BUSINESS OWN ENO OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT[] Office Manager <br /> IfAPPLICANT is not the BILLING PARTY proof of authorization to sign is required Title <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 the Same time It is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: O Replace 87 Unleaded <br /> CP I <br /> COMMENTS: <br /> ACCEPTED BY: 1 _Ir�� �, ==EMPLOYEE#: DATE: <br /> ASSIGNED TO: v � EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): V531 5 SERVICE CODE: ' PIE: ' (,A <br /> Fee Amount: Amount Paid +3 Payment Date t{ Z l5 <br /> Payment Type "fISP- Invoice# Check# 5 ( (�t 3 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />