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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT AUG 12 ?0';i <br /> SERVICE REQUEST ., <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Gas Station <br /> OWNER/OPERATOR <br /> Ru ie Padda CHECK if BILLING ADDRESS <br /> FACILITY NAME <br /> Waterloo Shell <br /> SITE ADDRESS EWaterloo Rd Stockton 95215 <br /> 4315 Street Number Direction I Street Name City Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> ( 209) 931-3674 6� <br /> PHONE#Z EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> Megan Mitchell CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> Elite IV Contractors <br /> ( 209) 461-6337 <br /> HOME or MAILING ADDRESS FAX# <br /> 2535 Wigwam Dr ( 209) 461-6342 <br /> CITY Stockton STATE Ca Z'P 95205 <br /> BILLING ACKNOWLEDGEMENT: 1, 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 me or my business as identified on this form. <br /> 1 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: DATE: 8/12/2016 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT U Office Assistant <br /> If APPLICANT is 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. <br /> TYPE OF SERVICE REQUESTED: Replaced Red Jacket Relay REL' ENT <br /> COMMENTS: <br /> o,t <br /> H a NMC <br /> F� <br /> ACCEPTED BY: {r? EMPLOYEE#: DATE: C� l _I <br /> ASSIGNED TO: EMPLOYEE#: DATE: <76 I i <br /> Date Service Completed (ifalrea completed): 8/11/16 SERVICE CODE: i < PIE: j <br /> Fee Amount: �� , C t, Amount Paid17 Payment Date /Z <br /> Payment Type / Invoice# 71 C k# Rece' ed By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />