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SAN JOAQUIN COUNTY ENVIRONMENTAL 1IRUR9TE. RTMENT <br /> SERVICE RE UF3S+'In,' 4,tpr-, — <br /> — <br /> Type of Business or Property FACILII WTD'#'= SERVICE REQUEST# <br /> Gas Station S r,66 C-�7 b <br /> OWNER/OPERATOR <br /> Blit CHECK If BILLING ADDRESS <br /> FACILITY NAME Fast 8 Easy Mart Chevron Morada <br /> SITE ADDRESS Stockton 95205 <br /> 10878 Seeet Number I DiAlon I HWY 99 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 ERT• APN# LAND USE APPLICATION# <br /> (209 1 931-6154 <br /> PHONE#2 Ear. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR <br /> Carie Miller CHECK((BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> Elite IV Contractors 209 461-6337 <br /> HOME or MAILING ADDRESS FAN# <br /> 2535 Wigwam Dr ( ) <br /> CITY Stockton STATE CA Zip 95205 <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of some, <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 /> CDUNTY Ordinance Codes,Standards,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: C44,� W4&2 DAT :: <br /> E 4/28/16 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AG ENT IR Office Manager <br /> IfAPP/JCANT is nor the BILLING PARTY.proof of authorization losign 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: Replaced 91 Leak Detector f PA <br /> COMMENTS: Ct.'NE, <br /> APR <br /> ?9? <br /> 8AN jo <br /> Hsi4V,aoov��,t <br /> ACCEPTED BY: EMPLOYEE M DATE: <br /> ASSIGNEDTO: r EMPLOYEE#: DATE: <br /> Date Service Completed (it already completed): 4/27116 <br /> SERVICE CODE: (,� P I E: .22509 <br /> Fee Amount: �' Amount Pal 3eD Payment Date �q l <br /> Payment Type /5G� Invoice# C k# 71 V�,L Rec ived By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />