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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Gas Station &9_00' u <br /> OWNER/OPERATOR Rupi Padda <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME Waterloo Shell <br /> SITE ADDRESS 4315 1 E Waterloo Rd Stockton Ca <br /> Street Number Direction Street Name Cit __ FZIp Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PH�vl EXT. APN# LAND USE APPLICATION# <br /> ( ) 931-3674 <br /> PHONE#2 ExT• BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR Megan Mitchell <br /> CHECK if BILLING ADDRESS <br /> BUSINESS NAME Elite IV Contractors PHONE# ExT. <br /> 209 461-6337 <br /> HOME or MAILING ADDRESS 2535 Wigwam Dr �209 ) 461-6342 <br /> CITY Stockton STATE Ca ZIP 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. A,q <br /> I also certify that 1 have prepared thi pplication and that t e work to be PeHorfned will be done in accordance with all SAN JOA*6;!�j N <br /> COUNTY Ordinance Codes,Standar STA and FEDERA l s. / FI�� T <br /> r. <br /> APPLICANT'S SIGNATURE / /r7 DTE: 11115/20164* 4?'? <br /> O <br /> PROPERTY/BUSINESS OWNER❑ E} /MANAGER ❑ E AUTHORIZED AGENT LQ Office Assistant 01� <br /> U <br /> IfAPPL1CANT is not the BI LIN PARTS proof of authori on to sign is required Title <br /> AUTHORIZATION TO RELEASE I FO MANAGER <br /> When applicable,1,the owner or operator of the property located at the <br /> above site address, hereby authorize th elease 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 a b -and at the same time it is <br /> provided to me or my representative. f <br /> TYPE OF SERVICE REQUESTED: r--- Ya }j ti <br /> 1 Laaaa V Laa�D <br /> COMMENTS: <br /> �X�fG�llf� Usr JAN 17 2017 <br /> ENVIRONMENTAL HE LTH <br /> DEPARTMENT <br /> ACCEPTED BY: �•` , EMPLOYEE M DATE: ' <br /> ASSIGNED TO: EMPLOYEE M DATE: 1 <br /> Date Service Completed (if already completed): SERVICE CODE: I p E, L3 <br /> Fee Amount: 2t' Amount Paid5/-'-)S--SD Payment Date 9-// <br /> Payment Type Invoice# Ch k# 6X/. / 1L Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 D <br />