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SAN JOAQUIN I;OUNTY ENVIRONMENTAL HEALTH O—PARTMENT <br /> SERVICE REQUEST <br /> ;;,ype of Business or Property FACILITY ID# SERVICE REQUEST# <br /> oS <br /> OWNER 1 OPERATOR CHECK If BILLING ADDRESS❑ <br /> Pacific Gas and Electric <br /> FACILITY NAME <br /> SITE ADDRESS Stockton 95204 <br /> 4040 Street Number I Direction West Lane Street Name Cit Zip C e <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number treat Name <br /> CITY STATE ZAP <br /> PHONE#1 ExT APN# LAND USE APPLICATION# <br /> PHONE#2 Exr. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> Michael A.Armour CHECK If BILLING ADDRESS® <br /> BUSINESS NAME PHONE# Ex . <br /> Armour Petroleum Service and E ui ment Corporation 707 437-6668 <br /> HOME Or MAILING ADDRESS FAX# <br /> PO BOx 507 (707 ) 437-4357 <br /> CITY Vacaville STATE CA ZIP95696-0507 <br /> BILLING ACKNOWLEDGEM NT: 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 •k to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE and E •RALta <br /> fs. <br /> APPLICANT'S SIGNATURE: DATE: 12/06/07 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT® Contractor <br /> IJAPPLICANT 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: <br /> COMMENTS: I D <br /> l zIZ-710 REI VED <br /> � <br /> � - 1", DEC 10 2007 DEC 1 0 2007 <br /> �Z pv" IIj �° ~ SAN JOAQUIN COUNTY ENVIRONMENT HEALTH <br /> ACCEPTED BY: HEALTT LMPL`OTW41.1 Ijtt�' 1J <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P I E: <br /> Fee Amount: 04 Amount Paid _ Payment lbate ; B <br /> Payment Type Invoice# Check# q Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />