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SAN JOAQUII, —OUNTY ENVIRONMENTAL HEALTH . -PARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> GAS STATION FA0002121 5 KC0 7 c l> <br /> OWNER/OPERATOR <br /> Lori Toccoli — executor — DBA JAMAR SERVICE ESTATE JAY MCILRAcKifBILLINGADDREss❑ <br /> FACILITY NAME JAMAR SERVICE <br /> SITE ADDR ggS <br /> 075E Main Street Stockton 95215 <br /> Street Number Direction Street Name City Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> PO BOX 326 Street Number Street Name <br /> CITY Stockton STATE CA ZIP 95201 <br /> P O�Lt�J9464 1431 <br /> #1 EXT. APN# LAND USE APPLICATION# <br /> ( ) <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> (209 ) 462-8707 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> Lori Toccoli CHECK If BILLING ADDRESS <br /> BUSINESS NAME � <br /> P V EXT. <br /> JAMAR SERVICE 8462-8707 <br /> HOME or MAILING ADDRESS FAX# <br /> PO BOX 326 (209 )462-6171 <br /> CITY Stockton STATE CA ZIP 95201 <br /> BILLING ACKNOWLEDGEMENT: 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 my business as identified on this form. <br /> I also certify that I have prepared this lication and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,S TE a0&fFQQRAL laws. <br /> APPLICANT'S GNATURE: �_� DATE: 8/30/2016 <br /> PROPERTY/BUSINF.S WNEOPERA OR/MANAGER ❑ OTHER AUTHORIZED AG Owner/EXeCutOr <br /> /f APPL/CANT 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 /> PAVAA- <br /> TYPE OF SERVICE REQUESTED: —����� ti o} FSE � <br /> COMMENTS: A UG 3 O <br /> n : Z <br /> D1CyaaG-e GJP o�neSAN CoAQU6 <br /> FtyHR1N , <br /> 1tgLT � � N <br /> Dqr4l� <br /> T <br /> ACCEPTED BY: \ �+ EMPLOYEE#: DATE: , 5C,// <br /> ASSIGNED TO: EMPLOYEE#: DATE: 9/- 2-5c_ /�U/_ <br /> Date Service Completed (if already completed): SERVICE CODE: / '� P/E: / <br /> Fee Amount: ' - Amount Pal i? C� Payment Date <br /> Payment Type Invoice# Check# �Z(p Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />