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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # SERVICE REQUEST # <br /> Gas Station 00 A <br /> OWNER / OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> Charter Way Chevron <br /> SITE ADDRESS Dr Martin Luther King Jr Blvd Stockton 95206 <br /> 508 Street Number Direction Street Name City X i ode <br /> HOME or MAILING ADDRESS (if Different from Site Address) RE IE T <br /> Street Number Street Name v D <br /> CITY STATE ZIP MA <br /> PHONE #1 ExT. APN # LAND USE APPLICATION # $AN JCA <br /> ( ) Li �ENVI JOAc) QlQUIN C pU n, <br /> PHONE #2 ExT. BOS DISTRICT L bwcw4w IOWE, V L <br /> T <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> James Otto Contractor ( Project Coordinator) CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE # ExT. <br /> LC Services 559 444- 1730 <br /> HOME or MAILING ADDRESS FAX # <br /> 3887 N . Valentine Ave . ( ) <br /> CITY Fresno STATE CA ZIP 93722 <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 . <br /> APPLICANT' S SIGNATURE : DATE . 02/28/2020 <br /> PROPERTY / BUSINESS OWNER ❑ 'OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT <br /> IfAPPLICANT 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 : S� <br /> COMMENTS : MAR ® 3 2020 <br /> ENVIRONMENImP L HEALT <br /> ® EPM� ITMENT <br /> i <br /> ACCEPTED BY: �7' EMPLOYEE # : DATE : 2W <br /> ASSIGNED TO : EMPLOYEE # : DATE : 40 <br /> Date <br /> Date Service Completed ( if already completed) : SERVICE CODE : PIE : <br /> Fee Amount: 4 ', J , C Amount Pal t � Payment Date <br /> Payment Type � Invoice # Check # 76L 7 <br /> Received By : <br /> Golden Rod <br /> EHD 48-02-025 SR FORM ( ) <br /> REVISED 11 /17/2003 <br />