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i • <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property /�FACILITY <br /> �ID# �SERVICE <br /> 7RE ]SST# <br /> Gas Station FAW01 C1101 .�JJ� <br /> OWNER/OPERATOR <br /> CHECK if BILLING ADDRESS <br /> Ja raj Brar <br /> FACILITY NAME Stop N Shop <br /> SITE ADDRESS <br /> 1856 County Club Blvd Stockton 95204 <br /> Street Number I Direction Street Name city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Same Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT• APN# LAND USE APPLICATION# <br /> ( 209 ) 250-6877 <br /> PHONE#2 EXT. BOS DISTRICT---TN CODE <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR Carrie Miller 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 ( 209) 461-6342 <br /> CITY Stockton STATE CA ZIP 95205 <br /> BILLING ACKNOWLEDGEMENT: 1, 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 t ' appli tion and that the work to e performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Stand ids,ST E and FEDERA laws.q <br /> APPLICANT'S SIGNATURE: / DATE: 12/6/17 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT® Office Manager <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: Replaced 87 Leak Detector from Red Jacket to VMI <br /> COMMENTS: <br /> C,L' ' 062017 <br /> ENVIRONMENTAL HEALTH <br /> ACCEPTED BY: �- EMPLOYEE#: -l cc DATE: <br /> ASSIGNED TO: GJ EMPLOYEE#: I 41k DATE: I <br /> Date Service Completed (if already completed): SERVICE CODE: 1 w PIE: <br /> Fee Amount: Amount Paid L�S��QU 'ayment Date ro -7 Q 6L7 I <br /> Payment Type �� Invoice# Ch # ���Q� Recei ed By: <br /> EHD 48-02-025 wQ, `t/� 6 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 O <br />