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MAY 0 5 2016 <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT •• � � . <br /> SERVICE REQUEST •�'° `` <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Gastation Min Mart ,!5�PC)6-7 <br /> 49b3 <br /> OWNER/OPERATOR <br /> Edger Rizkalla CHECK if BILLINGADDRESSE] <br /> FACILITY NAME Arco AM PM <br /> SITE ADDRESS West Valpico Rd Tracy 95376 <br /> 550 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 ) 836-3327 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> Carrie Miller CHECK If BILLING ADDRESS® <br /> BUSINESS NAME Elite IV Contractors PHONE# EXT. <br /> 209 461-6337 <br /> HOME or MAILING ADDRESS 2535 Wigwam Dr 'A109 461-6342 <br /> CIT" 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 HE,ALi,ii DEPARTMENT hourly charges associated with this project <br /> or activity will be billed to me or nuy business as identified on this form. i <br /> I 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. 5/5/16 j <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AuTtIORjzED AGENT IR Office Manager <br /> i <br /> IfAPPLIC,4iYT is not the BiL[.1,vt;PART),piwof 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 ancJ Ayltly1�3r��time it is <br /> provided to me or my representative. 7 Int�T <br /> TYPE OF SERVICE REQUESTED: ColdStart — u44 V <br /> 7 I I <br /> f6 <br /> I <br /> COMMENTS: <br /> SAN dOgQUIN T ENVIROIyITV <br /> HEgL7f!DEENTCOONPART1yENT <br /> ACCEPTED BY: EMPLOYEE#: DATE: 5 )le <br /> ASSIGNED TO: i !t ML EMPLOYEE#: DATE: 5 fj <br /> Date Service Completed (if already completed): i SERVICE CODE: ccA 0 PIE: 2W6 <br /> Fee Amount: —4 MAmount Paid _�qD Payment Date 5� j <br /> Payment Type / SAV . Invoice# Check# S b Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/1712003 <br />