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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property �ayy��FACILITY ID# SERVICE REQUEST# <br /> Gas Station P�X®510 I W,v0-7 0 9 LI <br /> OWNER i OPERATOR <br /> Chris Arbabian CHECK If BILLING ADDRESS <br /> FACILITY NAME Lathrop Shell <br /> SITEADDRESS 16500 S Harlan Rd Lathrop 85269 <br /> street Number Direction Street Name city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 ExT• APN# LAND USE APPLICATION# <br /> ( 916 ) 518-8378 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR Megan Mitchell <br /> CHECK if BILLING ADDRESS <br /> BUSINESS NAME Elite IV Contractors PHONE# Exr• <br /> 209 461-6337 <br /> HOME Or MAILING ADDRESS 2535 Wigwam Dr FAX# <br /> ( 209 ) 461-6342 <br /> CITY Stockton STATE Ca ZIP 95269 <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 t- e perf rano will be done in accordance with all SAN JoAQUIN <br /> COUNTY Ordinance Codes,Standa s STATE and FEDE laws. <br /> APPLICANT'S SIGNATURE: ��L�' DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERAT /MANAGER❑ OTHER AUIVRIZED AGENT La Office Assistant <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: Replace(4)dispensers with GB Encore 700s&Bravo conversion frames,with new Ve ware <br /> COMMENTS: <br /> �N <br /> Q <br /> LTH OEp�h rq�rY <br /> raFM <br /> ACCEPTED BY: /�/' EMPLOYEE#: DATE: f <br /> ASSIGNED TO: U r EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: -2 3.-> P f E: <br /> Fee Amount: L{� Amount Pa , v2) Payment Date �� <br /> Payment Type �� Invoice# Ch k# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />