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SAN JOAQU*OUNTY ENVH2ONMENTAL HEALTWPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Gas station s <br /> OWNER/OPERATOR <br /> Phillip 66 Comapny CHECK If BILLING ADDRESS O <br /> FACILITY NAME <br /> Shell Station <br /> SITE ADDRESS 1206 E March Lane Stockton 95210 <br /> Street Number I Direction Street Name CIN Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 1380 San Pable Avenue <br /> Street Number Street Name <br /> CITY Rodeo STATE CA zip 94572 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> ( 510)245-4423 104-160-04 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> Jeanne Hornsey CHECK If BILLING ADDRESS <br /> BUSINESS NAME ATC Group Services LLC PHONE# EXT. <br /> 209)579-2221 <br /> HOME Or MAILING ADDRESS 1117 Lone Palm Avenue, Suite 201B FAX# <br /> (209 ) 579-2225 <br /> CITY Modesto STATE CA zip 95351 <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 /> 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. -311q(,77 <br /> y <br /> APPLICANT'S SIGNATURE: L l�� DATE: 3 I I 117 <br /> PROPERTY/BUSINESS OWNER❑ RATOR/MANAGER ❑ OTHER AUTHORIZED AGENT® Cons tint <br /> If APPLICANT is not the BILLING PARTY proof of authorization t0 sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, 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: <br /> COMMENTS: <br /> ACCEPTED BY: " EMPLOYEE M r 1 ! DATE: <br /> ASSIGNED To: / EMPLOYEE v / DATE: <br /> Date Service Comple ed (if already completed): SERVICE Co E: 1 E: <br /> Fee Amount: Amount Paid ` , Payment Date <br /> Chec <br /> Payment Type Invoice# k It z.. Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />