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SAN JOAQUII*OUNTY ENVIRONMENTAL HEALTI0EPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> GASOLINE DISPENSING FACILITY 3 <br /> OWNER/OPERATOR <br /> SANJ��AppY B I RLA CHECK if BILLING ADDRESS <br /> F�SW�GA� & MARKET <br /> SITE ADDRESS W 11TH STREET TRACY 95376 <br /> 515 Street Number Direction Street Name CI 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 /> (510) 414-5390 233-090031 <br /> PHONE R EXT. BOS DISTRICT �• LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQLUCYR S I LVAS-THOMAS CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# ExT. <br /> TOWN & COUNTRY CONTRACTORS, INC. 91J 636-9500 <br /> HOME or MAILING ADDRESS FAX# <br /> 3181 LUYUNG DRIVE STE A (916 )636-9507 <br /> CITYRANCHO CORDOVA, CA STATE CA ZIP 95742 <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 /> UNTY Ordinance Codes,Standards, STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT® CONTRACTOR <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to 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: C) I E i 4 EMPLOYEE#: � �-2 � DATE: <br /> ASSIGNED TO: Jv�, EMPLOYEE#: DATE: / Z L,C <br /> Date Service Completed (if diready completed): SERVICE CODE: i P 1 E: -3 GS' <br /> Fee Amount: 3 ( 5- O Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />