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EGEIVEL <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT NOV 0 9 20115 <br /> SERVICE REQUEST ENVIRONMENTAL <br /> Type of Business or Property FACILITY ID# SERVI Arr <br /> Gas StationFAdco —7� i� <br /> r 7 � 3 <br /> OWNER I OPERATOR Chris v CHECK If BILLING ADDRES&® <br /> FACILITY NAME Lathrop Shell <br /> SITEADDRESSHarlan Rd Lathrop 95330 <br /> wet Number alraction Sirvet Name city Zip <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE 91 EAT. APN# LAND USE APPLICATION# <br /> { 209) 403-3859 <br /> PHONEY Ea. SOS DISTINCT LOCATION CODE <br /> CONTRACTOR/SERVICE REQUESTOR <br /> RE@UESTOR <br /> Carrie Miller CHECK IfBILL INGAWRESs <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: I, the undersigned property or business owner, operator or authorized agent of some, <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 /> 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: C2A" ' w 'll DATE: 11/9/15 <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZXD AGENT 10 Office Manager <br /> If APPLICANT is not the BALING PAR TI;proof of authorization to sign is required IYtie <br /> AUTHORIZATION IQ 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. ,g <br /> TYPE OF SERVICE RE@VESTED: 87 Fill bucket Replacment C,° 37r AqY <br /> COMMENTS: 10 po <br /> 9 <br /> y �o <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: I(/�( EMPLOYEE M DATE: <br /> Date Service Completed (if already completed}: SERVICE CODE: H I P I E: pr✓ <br /> Fee Amount: cl�D-63141 Amount Pai 3 r0 Payment Date ///q/1,5— <br /> Payme <br /> l S— <br /> Payment Type 5� invoice# Ch # ®,Z ReceivedBy: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />