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.1 <br /> SAN JOAft COUNTY ENVIRONMENTAL HEALTHOPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Gas Station <br /> OWNER/OPERATOR <br /> Jivtesh GIII r1rxi L. <br /> CHECK if BILLING ADDRESS❑ <br /> FACII.nY NAME Arch Arco AMPM . APR 02 201 <br /> SITE ADDRESS sHWY99 fflRQNMENT4 Stockton 95215 <br /> 4855 Streel Number Direcaen cay zip Ceae <br /> HOME Or MAILING ADDRESS (If Different from Slte Address) <br /> Street Number Street Name <br /> CITY STATE Zip <br /> PHONE#I APN# LAND USE APPLICATION# <br /> (209) 948-2438 <br /> PHONE#Z Em. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR Kim White CNECiC N BILUNG ADDRESS <br /> BUSINESS NAME Elite IV Contractors PHONE# Ex <br /> 461-6337 <br /> HOME or MAILINGADDRESS 2535 Wigwam Dr. FAX#t ) 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,S and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: �/ . . - -'.�� , DATE; 4/1/2015 <br /> PROPERTY/BuswEssOwNEREI OPERATOR/MANAGER ❑ OTHER AUTRORIZEDAGENT❑ Office Manager <br /> If APPLICANT is not the BILLING PAR TT 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: Cold TLS/ Replace 87 Unleaded CPT <br /> COMMENTS: <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (If already Completed): SERYICECODE: PIE: <br /> Fee Amount: Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />