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SAN JOAQ -Mc.pprilq ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Propetr ENVIRONMENTAL I.-IL <br />Gas Station D E PART M ENT <br />-.-. FACILITY ID # \Li i I <br />FA- 0060 UK <br />SERVICE REQUEST # <br />'R._. U. 77 <br />OWNER / OPERATOR <br />Sam Hirsch CHECK if BILLING ADDRESS • <br />FACILITY NAME Short Stop <br />SITE ADDRESS 20 <br />Street Number <br />w <br />Direction <br />Turner Rd <br />Street Name <br />Lodi city <br />Ca <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Street Number Street Name <br />CITY STATE ZIP <br />PHONE #1 EXT. <br />(559) 366-0699 <br />APN # <br />ot-togol <br />LAND USE AppLIcATIoN # <br />PHONE EXT. #2 <br />( ) <br />ro BOS DisTc•c orog LOCATION CODE <br />0 a <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR Megan Mitchell CHECK If BILLING ADDRESSIZI <br />BUSINESS NAIVIE PHONE <br />Elite IV Contractors <br /># <br />( 209 461-6337 <br />EXT. <br />HOME or MAILING ADDRESS 2535 Wigwam Dr Fax # <br />(20q) 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. STATE and FEDERAL laws. <br />APPLICANT'S SIGNATURE: <br /> <br />Megoi Mr4heGG <br /> <br />DATE: 6/2/2017 <br /> <br />PROPERTY! BUSINESS OWNER]: OPERATOR / MANAGER 0 OTHER AUTHORIZED AGENT a Office Assistant <br /> <br />If APPLICANT is not the BILLING PARTY, 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: (...),S17 r e_A-03 ..-Li— PAYM ENT <br />COMMENTS: HEC6f <br />JUN O '2 2017 <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />_ <br />ACCEPTED By: 9--)QA (a EMPLOYEE #: DATE: tifj, . e;2._ _ I —7 <br />ASSIGNED TO: 07 b a otkv, Aktria „z. EMPLOYEE #: DATE: to • ,57 ,1 --- I '-) <br />Date Service Completed (if already completed): SERVICE CODE: I q $' PIE: a 0 3 <br />Fee Amount: 14110D 0 0 Amount Paid Li t e"? % Payment Date 6 (2. / /7 <br />Payment Type V 's t.a ck Invoice # CLicr IA- G 0\ Og 5-- Received By: <br />EHD 48-02-025 <br />REVISED 11/1712003 <br />SR FORM (Golden Rod)