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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property r JF�ACILITY ID# SERVICE REQUEST <br /> Gas Station �?� �� .S �� <br /> OWNER/OPERATOR <br /> Angle CHECK If BILLING ADDRESS <br /> FACILITY NAME Shell <br /> SITE ADDRESS 7700 Moreland Dr Stockton C1 � <br /> Street Number Direction Street Name Cit Zi 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) 957-5398 <br /> PHONE#2 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 209 461-6337 <br /> HOME or MAILING ADDRESS FAx# <br /> 2535 Wigwam Dr <br /> (209) 461-6342 <br /> CITY Stockton STATE Ca ZIP 95205 <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 me or my business as identified on this form. <br /> A <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•JOAyMtcNT <br /> COUNTY Ordinance Codes,Standards,STATE and FEDERAL laws. �4 C$7n/�O <br /> APPLICANT'S SIGNATURE: <br /> MeMitchea DATE: 8/4/2017 UG Oq - <br /> r�y <br /> PROPERTY IBUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT 0( Office AssistanbE�'�R°�'Nco� <br /> Il APPLICANT is not the BILLING PARTY,proof of authorization to sign is required Title OAF �hrq`tiry <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, I,the owner or operator of the property located at the LIF^T <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 flex Connector <br /> COMMENTS: <br /> AUG 0 4 2017 <br /> ENVIRONMENTAL HEALM <br /> 44 el -,.r'' <br /> ACCEPTED BY: �Jtl EMPLOYEE#: DATE: <br /> ASSIGNED TO: mo EMPLOYEE#: DATE: <br /> Date Service Completed (if gready completed): SERVICE CODE: 11E' <br /> Fee Amount: ) , Amount Paid ,U� Payment Date 8 <br /> Payment Typeri Invoice# Ch ck# Rec ive By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />