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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Gas Station S �A)07 7�)J to <br /> OWNER/OPERATOR <br /> Bill CHECK If BILLING ADDRESS <br /> FACILITY NAME Georges Mini Mart <br /> SITE ADDRESS 18662 18662 Highway 88 Lockeford 95237 <br /> Slroel Number I Dimeton Str..I Name C 21 Cotle <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 Ex. APN# LAND USE APPLICATION# <br /> ( 209 ) 814-3581 <br /> PHONE#2 Ezr. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> Megan Mitchell CHECK If BILLING ADDRESS® <br /> BUSINESS NAME Elite IV Contractors PHONE# Ear. <br /> 209 1 461-6337 <br /> HOME or MAILING ADDRESS 2535 Wigwam Dr FAX# <br /> ( 209 ) 461-6342 <br /> CITY Stockton STATE CA ZIP 95205 <br /> BILLING ACKNOWLEDGEMENT: 1, 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 /> COUNTY Ordinance Codes,Standards,STATE and FEDERAL laws. / �/�/ <br /> APPLICANT'S SIGNATURE: ! N%C.C/l!-2� DATE: <br /> 4/27/2017 <br /> PROPERTY/BUSINESS OIVNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT L'r Office Assistant <br /> IJAPPL/CANT lS not the BILLING PARTY proof of authorization 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 COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it Is available and at the same time it is <br /> provided to me or my representative. IO <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: <br /> S41'11 a <br /> a <br /> Z✓(o O., — ,,� /"1{r '�j,;I) "h '0' N°°Aly <br /> wF <br /> a> <br /> ACCEPTED BY: C EMPLOYEE#: DATE: ) <br /> ASSIGNED TO: EMPLOYEE#: DATE: IST <br /> Date Service Completed (if already completed): SERVICE CODE: �' OIL <br /> Fee Amount: ' C Amount Pai 7 dD Payment Date <br /> Payment Type 5� invoice# Ch k# 61 7_ZJC) Recel d By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />