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• 0 <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# (�Q SERVICE REQUEST# <br /> SPO <br /> Gas Station C"�%t7 3 c <br /> OWNER/OPERATOR <br /> Stockton Petroleum CHECK if BILLING ADDRESS❑ <br /> FACILITY NAME Westlane Fuels <br /> SITE ADDRESS <br /> 3300 N Westlane Stockton 95204 <br /> Street Number Direction I Street Name city ZiD Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> 1905 Street Number Navy Dr. Street Name <br /> CITY STATE LP <br /> Stockton CA 95026 <br /> PHONE#1 Em. APN# LAND USE APPLICATION# <br /> ( 209 ) 466-1682 <br /> PHONE#2 ExT. BOS DISTRICT LOCATION CODE <br /> 209) 462-8707 <br /> CONTRACTOR/SERVICE REQUESTOR <br /> RECIUESTOR <br /> Carrie Miller CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHDNE# Ext. <br /> Elite IV Contractors 1 209 461-6337 <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 ENVIRONMENTAI.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 /> 1 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: c/,LLtG2 WL&I21 DATE: 8/3/16 <br /> PROPERTY/BUSINESS OWN ER OPERATOR/MANAGER ❑ OTHER At THORIZEDAGENT[R Office Manger <br /> If APPLICANT is not the BILLING J ARTY,proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1,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: Hit Dispenser `7 7— <br /> COMMENTS:COMMENTS: - <br /> FC FNT <br /> 4110 �Fo <br /> ACCEPTED BY: � "` - EMPLOYEE#: DATE: <br /> ASSIGNED TO: GC �^ EMPLOYEE#: DATE: <br /> Date Service Completed (if already co leted): SERVICE CODE: PIE: <br /> Fee Amou 625.5 = �� 5 t�-/-7 Amount Pa �,;ZS�6-,�) Payment Date ��042 <br /> Payment Type � _ Invoice# Ch k# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/1712003 <br />