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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Fueling Facility ? ')' SR& <br /> OWNER OPERATOR Steve Kludt CHECK N BILLING AODRESSI� <br /> FACILITY NAME Kludt Petroleum <br /> SITE ADDRESS I E Pine St Lodi 95240 <br /> 1126 stmet Numbo Stan Name zip Coda <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Nems <br /> CITY STATE ZIP <br /> PHONE#1 ExT. APN a LAND USE APPLICATION e <br /> ( 209) 368-0634 0, <br /> PHONE#2 En' SOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR CHECK If BILLING ADORESS® <br /> Carrie Miller <br /> BUSINESSNAME PH E# En' <br /> Elite IV Contractors X09 461-6337 <br /> HOME or MAILING ADDRESS Fix# 461-6342 <br /> 2535 Wigwam Dr. 1 209 ) <br /> CITY Stockton STATE CA 25P 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 DEPAR'rME.Nr hourly charges associated with this project <br /> or activity will be billed to me or my business as identified on this forret. <br /> I. also certify that 1 have prepared this application slid that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUN'T'Y ordinance Codes-Standards,S�TA�TE and FEDERAL laws. <br /> ,S <br /> APPLICANT'S SIGNATURE: C� WZ&41 DATE: 11/12/15 <br /> PROPERT\'/BUSINESSOWNr.R❑ OPr.RATOR/MANAGER ❑ OTHER AUTHORIZED AGENTR Office Manager <br /> If APPLICANT is not the BILLING PARTI',proof of aathorization 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 COUNTS'ENVIRONMENTAL HEALTH DEPARTMENT as soon as it Is available and at the sante time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: Fill, Vapor , and Drop Tube replacment on 100 octane j �'F-+- <br /> COMMENTS: <br /> ACCEPTED BY: <br /> -_ , EMPLOYEE#I DATE: <br /> .�L <br /> ASSIGNEDTO: `I ' EMPLOYEEC DATE: ) L- Cl I <br /> V k"�CK�i <br /> Date Service Completed (If already completed): SERVICE CODE: I PIE: 2_3016 <br /> Fee Amount: Amount Paid 4:59 0. 0U Payment Date t 2-9-is <br /> Payment Type Invoice# Check# c)i9 OGj Re y'� —!:J <br /> PAYMENT 1 M ENT SR FORM(Golden Rod) <br /> EHD SED 1111 RECEIVED d <br /> REVISED 111f 7/2003 DEC tj9 201') <br /> DEC 0 9 2015 ENVIRONMENTA <br /> SAN JOAOUIN COUNTY aFAiT COM1pTt A T <br />