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K SAN JOAQUIo, _OUNTY ENVIRONMENTAL HEALTi. DEPARTMENT SERVICE REQUEST Type of Business or Property OQ� FACILITYID## Bob Hill SERVICE REQUEST # Commercial /Gasoline Sales BUSINESS NAME /J ('U�3`�� T U� I � -v3l OWNER / OPERATOR Franzen -Hill Corp(559 CHECK If BILLING ADDRESS© Dennis Cove HOME or MAILING ADDRESS FAX # FACILITY NAME 1100 North J Street (559 ) Food 4 Less ClTtulare SL,TAE ZIP 93274 SITE ADDRESS A Service Completed (if already completed): Manthey Road Stockton 95210 Street Number Direction Payment Type �, Invoice # Street Name Ci Zip Code HOME or MAILING ADDRESS (If Different from Site Address) 8014 Lower Sacramento Road Suite 1 Street Number Street Name CITY STATE ZIP Stockton CA 95210 PHONE #t EXT' APN # LAND USE APPLICATION # ( 209) 483-2342 /53... y_ PHONE #2 EXT. ( ) BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR OQ� COMMENTS: Bob Hill CHECK if BILLING ADDRESS BUSINESS NAME PHONE# Err. Franzen -Hill Corp(559 EMPLOYEE #:?� j, 688-2977 3009 HOME or MAILING ADDRESS FAX # 1100 North J Street (559 ) 688-1467 ClTtulare SL,TAE ZIP 93274 BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project specific ENVIRONMENTAL HEALTIi DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as identified n his form. I also certify that I have prepared this applicat' n and t t the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, Standards, ST E rVM RAL lhws. APPLICANT'S SIGNATURE: (/ "`!"— DATE: 2/11/04 PROPERTY/ BUSINESS OWNER 11 OPERATOR /N'IANAGER ❑ OTHER AUTHORIZED AGENT KI Contractor If APPLICANT is not the BILLING PARTY proof of authorization to sign is required Title AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available a *Ahe same time it is provided to me or my representative. rVF„��J�� TYPE OF SERVICE REQUESTED: OQ� COMMENTS: [ 0 N001A COVNt`I SP CNV �E R M�Ni ACCEPTED BY: EMPLOYEE #:?� j, DATE: SSV ASSIGNED TO: Ct EMPLOYEE M DATE' g � Service Completed (if already completed): (l SERVICE CODE: ((78_ :Z?oFDate P I E-0?- Fee ee Amount:Amount Paid .-�C/ Payment Date a O c f Payment Type �, Invoice # Check # (�� Received By: EHD 48-02-025 SR FORM (Golden Rod)