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SAN JOAQUIO OUNTY ENVIRONMENTAL HEALAEPAR fMCNT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> GAS STATION �' 4OD35_qqq <br /> Owt:ER 1 OPE70 �� n — �. -- ----- <br /> r / ��Q� p W�(1�I1. — � rNSC::'.f SILTING ADDRESS❑ <br /> FACILITY NAfLv-(�Am <br /> w 1�,^ <br /> .c'T.E A�r' CJT dW2,70 StreetNumber Direction. ^t � _ . ZCr_rip <br /> HOME Or MAILING ADDRESS I Different fron-.J11 tte A dre <br /> cb= Street Number Street Name <br /> C;TY nSTATE zip <br /> CSI <br /> MAI) . -_ cc�a3 - <br /> PHONE#1 EXT. +APN# LAND U: APPLICATION# <br /> PYt)NE#2 EXT. BOS DISTRICT I LOCATiONi'ODE <br /> _ CONTRACTOR / SERVICE REQUESTOR <br /> 1 R,:Qt1:.-TOR' - - <br /> BUSINL-'s NAMEPHONEY <br /> ELITE I"; CON'T.;_AC''OP.� SNC, (209) 461 -6337 <br /> HOME Or M,IJ TNG ADDRESS Fax 4 <br /> 2535 WIGWAM DRIVE (209 )461 -6342 <br /> CITY STOCKTON STATE GA ZIP 95205 <br /> BILLING ACKNOWLEDGEMENT. I, the undersigned property or business owner, operator or .luthorized -Igevt of same, <br /> acknowledge that all site and/or project specific ENVIRONMENTAL,HEALTH DEPARTMENT hourly charges a �ociated thi ; .oject or <br /> activity will be billed to me or rr;y business as identified on iiiis form. <br /> alst, certify that I have pr pared this application and that the work to be performed %will be done in accordance with ale ;N 'JAQUIN <br /> COUNTY Ordinance Codes,Standa=Snd EDE 1 s. <br /> APPTiCANT'S SIGNATURE: , DATE: <br /> PROPERTY/QIISINESSO\VNER❑ OPERATOR//MANAGER ❑ OTHER AUTIIORizFD AGEN _ 1 <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sigh 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: PAYMENT <br /> RECEIVrD <br /> NOV 10 20M <br /> SAN JOAQUIN COUM <br /> ENVIRONMENTAL: <br /> APPROVED BY: EMPLOYEE#: ATE: I t I D f03- <br /> ASSIGNED TO: EMPLOYEE#: 1f3o DATE: I l D <br /> Date Service Completed (if already completed): SERVICE CODE: "\(�r PI E: d <br /> Fee Amount: Z Amount Paid Payment Date <br /> Payment Type / Invoice# Check# _T77T- <br /> R ceived By: <br /> EHD 48-01-025 SERVICE REQUEST FORM <br /> aGvt¢Fn r,-r,-ng <br />