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RECEN" D <br /> .� <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUJ§ 3 0 2016 <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Gas Station ENVIRONMENTAL H ALTHMI=MA <br /> �J�007��fa <br /> OWNER/OPERATOR <br /> Rinku V-R t)cb�7 I CHECK if BILLING ADDRESS 1-3 <br /> /I <br /> FACILITY NAME <br /> West Lane Chevron <br /> SITE ADDRESS <br /> 4747 N West Lane Stockton 95210 <br /> Street Number Direction 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 ) 472-1639 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> Carrie Miller CHECK H BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> Elite IV Contractors 209 461-6337 <br /> HOME or MAILING ADDRESS FAX# <br /> 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.HEALTii DEPARTMENT hourly charges associated with this project <br /> or activity will be billed to me or my business as identified on this form. <br /> also certify that I have prepared this application and that the work be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Slandau•Al STATE and FEDERA aws. <br /> APPLICANT'S SIGNATURE: DATE: >' <br /> PROPERTY/BCSINESSONN'NER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED ACENT Wl Office Manager <br /> tI APPLICANT is not the BILLLVG 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: Replace 87& 91 -Spill Bucket u ST t — <br /> RPIECE ED <br /> 1 3 0 2016 <br /> SANRp LIME TMETf� <br /> PAR <br /> CCEPTED BY: EMPLOYEE#: DATE: (q- .. <br /> ASSIGNED TO: C EMPLOYEE#: DATE: •1/�, <br /> Date Service Completed (if already mpleted): 1 b1 SERVICE CODE: IC1� PIE: Z�`� <br /> Fee Amount: (per `� Amount Paico ( s d Payment Date 30 <br /> Payment Type / �� Invoice# Ch 'C94' Recefved By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />