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SAN JOAQUISrCOUNTY ENVIRONMENTAL HEALTH-00EPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Gasoline Sta'tiori �0 3 -71 S <br /> OWNER/OPERATOR CHECK If BILLING ADDRESS❑ <br /> CsSVIZON Frlt> 7UGTS GO. <br /> FAcim NAME*q 5Z604 604, <br /> SREADDRESS 3775 _ -rr2Gy SK/J. '1'{gc. 015504 <br /> Street Number Direction Street Name Ci Zi 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 /> ( ) <br /> PHONE#2 EJ T. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> I SERVICE REQUESTOR <br /> REQUESTOR CHECK If BILLING ADDRESS <br /> Ag' �, Coianino , �oj. Hgr. <br /> BUSINESS NAME PHONE# EaT' <br /> RHL pe-sig" &rDuP , <br /> HOME or MAILING ADDRESS FAX# <br /> 340 ArnaW Drive Suite (425) 313 - <br /> CITY martince <br /> STATE CA ZIP 111+ <br /> 6 <br /> 5 <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator orfauthorized agent o same <br /> acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated wl I mis 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,STATE and FEDERAL laws. Z <br /> APPLICANT'S SIGNATURE:_ 4ry}.+1r�^^^r DATE: r - Zyy1 04' <br /> PROPERTY/BUSINESS OWNER 13 OPERATOR/MANAGER OTRERAVTnORIZEDAGENT X fte(a M2mMir <br /> If APPLICANT isnot the BILLING PAR TYproofofauthorizationtosign isrequired 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. It 4r-CSIT <br /> 111— <br /> TYPE OF SERVICE REQUESTED: RG 91P 9Ctrofit F712n GhGG1C EIVED <br /> COMMENTS: Plan [,Fleck for spill containment rep1zeer^4n+. J8 ZuA <br /> UL`� <br /> SAN JOAQUINcr`ut4v <br /> HFetviFtON,OEF'Hii t NicNIT <br /> ACCEPTED BY: vD/l (�� EMPLOYEE#: g 31-7 DATE: -717-11 <br /> ASSIGNED TO: /^ EMPLOYEE#: 3 J O DATE: 17 7"' OLf <br /> Date Service Completed (if already completed): SERVICE CODE: /PIE: 3(53 <br /> Fee Amount: 1 6i Uo Amount Paid Z-7 Gj (�o I Payment Date "7J-,)-W0 q <br /> Payment Type Invoice# Check# FI)0 q3 Yi Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />