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SAN JOAQI COUNTY ENVYRONMENTAL HEALDEPARTMENT <br /> .. SERVICE REQUEST <br /> Type of Business or Property Z:'A; <br /> ILITY ID# SERVICE REQUEST# <br /> GAS STATION _ ooo 7-,1€'6 00 3577 y <br /> OWNER/OPERATOR — <br /> CHECK If BILLING ADDRESS E] <br /> FACILITY NAME � ' <br /> SITE ADDRESS <br /> / r+ Street Nu r Direction Slreel a C Zi Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) _ IF <br /> Site etNum4er Street Name <br /> CITY ' STATE .- ZIP <br /> PHONE#t ExT. APN# LAND USE APPLICATION# <br /> VC7 q�b-I? 9 <br /> PHONE#2 ET. BOS DISTRICT LOCATION CODE <br /> ( 1 <br /> CONTRACTOR/ SERVICE REQUESTbR <br /> REQUEST + <br /> CHECK if BILLIW ADDRESS <br /> BUSINESS NKMEELITE IV CONTRACTORS, INC. PHONE# EXT. <br /> j209 ) 461 -6337 <br /> HOME or MAILING ADORESS ` FAX# <br /> 2535 WIGWAM DRIVE (209 )461 -6342 <br /> CITY STOCKTON STATE CA ZIP 95205 <br /> BILLING ACKNOWLEDGEMENT:-I, the undersigned property orbusiness 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 or <br /> activity will be biiled to me or my business as identified on this Conn. <br /> I also certify that I have prepared this a plication and that the work to be performed will be docle in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards ATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: - (Z"Z0 <br /> PROPERTY/BUSINESS OWNER[I OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT <br /> IfQPVL/CANT is nol the BLLLLNG P,IRTY pr0ofof 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 /> .Dove site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br /> inforrywioh t0 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: L( 7— R' tCEIVED <br /> COMMEWS: <br /> OCT 2 0 2003 <br /> PANAQUIN COUNTY <br /> WL�HEALTH SMI CES <br /> ENVIRONMENTAL HEALTH ON" <br /> APPROVED BY: EM <br /> !(�(� i DATE: <br /> ASSIGNED TO: EMPLOYEE#: P373 DATE: 16 63 <br /> Date Service Completed (if already completed): SERVICE CODE: /!fig P t E: -;�30e <br /> Fee Amount: �(70o Amount Paid 1k a-T7 __ Payment Date L D f a:3 <br /> Payment Type Invoice# Check# -7-70L Received By: <br /> EEVISED 5-0 - SERVICE REQUEST FORM <br /> REVISED GS-02 <br />