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SAN JOAQU. COUNTY ENVIRONMENTAL HEAL- DEPAR,rml?NT <br /> SERVICE ��EC}YTE��T <br /> Type of Business or Property FACIL!TY 1D# SERVICE REQUEST <br /> GAS STAT1tiN <br /> OWNER l OPE;'A OR n <br /> CHECK If BI!.UNG t ODraSs <br /> stn, — - <br /> 1 <br /> :>treet M,mber <br /> _,7ire -- -Ireet Narnr - - — <br /> r: �1A.LIW'-.ADDRf'' •! different fmr. ,i!-Adciressl I <br /> ��JJ� <br /> 1-_—_-.—'------- � —• —.--__—.� •—Sfrr^:Numt.cr "_`"� heel <br /> S TE <br /> 0 . <br /> ExT. APN# LAND USE APPLICATION + <br /> . •�q, �� 3- 313 _ _ _ _ _ _�-•— _ <br /> -�,`'-i:'-- - — -- ------- <br /> EXT. - - --- —-- - --- -..—.------.=BOS DiSTRIC7 !� Lf �1CgT10':CODI? <br /> i I <br /> Mi 'I :- CTO-R I .-EQUESTOR <br /> CHECK If P-iLLIn'-;di-.:".•-- <'- <br /> B. Eli 1.TE I:1 CONT'.-.A1_: `OR I . PHONE# <br /> 2091461 -6337 — <br /> Hc;qie or iJlHlurlc A:ICRt�S `-- — - --- -- — Fax# <br /> 2535 WIGWAM DRIVE (209 )461 -6342 <br /> CITY STOCKTON STATE CA ZIP 9 5 20 5 <br /> BU '..!"G Af7KNOWLEDGEMENT: I, tit undersigned property business owner, operator or authorized went of <br /> acl r ::!:�d;,f thal all site and/or project specii c ENVIE?ONE:l"J-'r.:_HEN' -'D'�'ARTMENT hourly charges associated with Oiii projc:-"o <br /> aL:t ;riled to me or myJausiness a! Aentilied cn;his}t.rni <br /> that I have n; I ared this ppI.cation and that '!te work t be •ier oimcd will be done in accordance Nvith all SAN.!0Af)UIN <br /> f`uUNTY C-.linance C'_>des,Staodar, - NATE and FLJ L v ,. <br /> F"T'17CANT'SSI(;NATURE: �v� DATE. <br /> 1 i(oi-F.RTY/BIIsINESs OWNER❑ OPERA.GR%kl[ANAC.:_fi ❑ JTHFIt AUTHORIZED AGENT <br /> If APPLICANT IS/101 the f311_LING 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 DCPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. ENT <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: <br /> SAN JOp(]um COUtm <br /> HCH DEpARTM T <br /> APPROVED BY: ' EMPLOYEE#: v, DATE: <br /> i X7 <br /> ASSIGNED T0: MPLOYEE#: 5DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: ` <br /> Fee Amount: Amount Paid 7CI'DD Payment Date <br /> Payment Type Invoice# Check# 7713 Received By: <br /> EHD 48-01-025 SERVICE REQUEST FORM <br /> pGvicFn r,-r,-ng <br />