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Mar 01 04 01:36p Frr zen Hill 559r-91467 p.4 <br />woo l;6 Akty, nWi:d4q :;ISIA 'Uollewlo;ul avow Io J 'JS/UaS xe; Ia)lewXyJ IJ D ,(q paAlaoal Senn XT!; sµyl <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />A �94Q <br />COfAMENTS: <br />FACILITY 1D # <br />ACCEPTED BY: <br />SERVICE REQUEST # <br />Commercial /Gasoline Sales <br />DATE: <br />PHONE# <br />[' U <br />Lj <br />OWNER 10 P ERATOR <br />Date Service Completed (if already completed): <br />688-2977 3009- <br />009HCUE <br />CHECK if BtLLtHG <br />Dennis Cove <br />FAX # <br />;LI -5. 4g-0 <br />ADDRESS,® <br />FACILITY NAME <br />(559) <br />688-1467 <br />CIT' ulare <br />Food 4 Less <br />zip <br />93274'.1 <br />StiEADDREss 349 <br />Manthey <br />Road <br />Stockton 3&�4A . "• <br />Street Number Diro ";oil <br />Strett <br />Name <br />city (C <br />HOME or MAILING ADDRESS (it Different from Site Address) <br />8014 Lower Sacramento Road Suite '1 <br />Street Number <br />IttegtNrme <br />CITY <br />STATE zip <br />Stockton <br />CA 95210 <br />PHONE#S E,rr. <br />APN9 <br />LAND USE APPLICATION' <br />( 209) 483-2342 <br />`53�. <br />l— <br />PHONE #2 EX'• <br />BOS DISTRICT <br />LocAT ION CODE •', . <br />CONTRACTOR 1 SERVICE REQUESTOR <br />REQUESTOR <br />A �94Q <br />COfAMENTS: <br />Bob Hill <br />ACCEPTED BY: <br />CHECKU BILLING ADDRESS <br />BUSINESS NAME <br />DATE: <br />PHONE# <br />EM. <br />Franzen -Hill Corp559 <br />Dm E' <br />Date Service Completed (if already completed): <br />688-2977 3009- <br />009HCUE <br />H CUEor MAILING ADDRESS <br />Fee Amount: <br />FAX # <br />;LI -5. 4g-0 <br />1100' North J Street <br />Payment Type �/ Invoica # <br />(559) <br />688-1467 <br />CIT' ulare <br />STaT,E <br />zip <br />93274'.1 <br />tf. <br />BILLING ACICNOtiyLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same; <br />acknowledge that all Site and/or project specific ENVIRONMENTAL I-IEALTI-I DFPARTMFNT hourly charges associated with this project or <br />activity will be billed to me or my business as, identified his form. <br />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.:';=`c'"' <br />COUNTY Ordinance Codes, Standards, S P RAL laws. <br />APPLICAN'T'S SIGNATURE: DATE.• 2111104 <br />PROPERTYJRUSLNESSOWNER❑ OPERATORIIVIANAGER ❑ OTHER AVnIORIZ£DAC£NTKI Contractor <br />ifAPPLIC IN7- is not the B]I.f rr'c Pr1 RTY, proof of a utiiork"don to sign is required <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located it the <br />above site address, hereby authorize the release of any and all results, geotechnical data and/or environmentallsite assessment.-' ' <br />information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEAL ---H DEPARTMENT as soon as it IS avaaiilabl he same time it :`:; <br />provided to me or my representative. P. <br />TYPE OF SERVICE REQUESTED: <br />A �94Q <br />COfAMENTS: <br />�-`•• <br />p pUIta NT AL <br />SAN <br />ACCEPTED BY: <br />EMPLOYEE #: <br />DATE: <br />ASSIGNED TO: <br />1:iff <br />EMPLOYEE'. <br />Dm E' <br />Date Service Completed (if already completed): <br />SipmC£COUE: f� P I E: Z3� <br />Fee Amount: <br />Amount Paid <br />;LI -5. 4g-0 <br />Payment Dato a t{ O t f <br />Payment Type �/ Invoica # <br />Check # (,-3[-7<7 Received E �t!� <br />EHD 48-02-025 SR FORM (Golden Rod) <br />Ad SZ Lb 6 1700ZISZ/Z :211'20 ZZ:@62d 0999 9S6 wolJ <br />