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RECEIVED <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MAR 10 2017 <br /> SERVICE REQUEST ENVIRONMENTAL <br /> Type of Business or Property FACILITY ID# ppSERVICEREQK51WARTIV ENT <br /> Gas Station <br /> OWNER/OPERATOR <br /> Bill CHECK If BILLING ADDRESS <br /> FACILITY NAME Flame Mini Mart <br /> SITE ADDRESS 1301 W Kettieman Lane Lodi 95240 <br /> Street Number I Direction Street Name c1tv ZIP Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE 2:IP <br /> PHONE#1 ExT• APN# LAND USE APPLICATION# <br /> ( 209 ) 814-3581 <br /> PHONE#2 ExT• BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR <br /> Megan Mitchell CHECK If BILLING ADDRESS <br /> ON # Exr. <br /> BuslNess NAME Elite IV Contracors PH206 461-6337 <br /> HOME or MAILING ADDRESS 2535 Wigwam Dr FAX# <br /> (209 ) 461-6342 <br /> CITY Stockton STATE Ca ZIP 95205 <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: I�' ��-- <br /> PROPERTY/BUSINESS OWNER 13 OPERATOR MANAGER ❑ OTHER AUTHORIZED AGENT OfficeASSiStant <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: to 22— <br /> /—�-C 4- ECEW, <br /> — <br /> COMMENTS: PAYMENT <br /> RECeNED WAR O 6 2017 <br /> + � 9 2417 EiNVIRONMENTAL <br /> TH DEPARTMENT <br /> ACCEPTED B , EMPLOYEE#: DATE: -z 16b3 <br /> ASSIGNED TO: EMPLOYEE M DATE: b h <br /> Date Service Completed (if already completed): SERVICE CODE: r P E: Z <br /> Fee Amount: mount P Payment Date <br /> //o <br /> Payment Type i-Sl,� I Invoice# Ch k# ��� Rec ived By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />