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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# r SERVICE REQUEST# <br /> Gas Station 40313 U� l a <br /> OWNER/OPERATOR n <br /> Paul Judge CHECK if BILLING ADDRESS <br /> FACILITY NAME Chevron <br /> SITEADDRESS 437 N Wilson Way Stockton 95205 <br /> Street Number I Direction Street Name city ZipCode <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 /> (209) 942-2344 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR Megan Mitchell CHECK if BILLING ADDRESS® <br /> BUSINESS NAME PHONE# EXT. <br /> Elite IV Contractors ( 209) 4r2l-6337 <br /> DOME or MAILING ADDRESS FAx# <br /> 2535 Wigwam Dr <br /> ( 205 461-6342 <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 1 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: Megan M`tckelt DATE: 9/1/2017 <br /> PROPERTY/BUsrNFss OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT Ill Office Assistant <br /> IfAPPLICANT is not the BILLING PARTY,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 a r n atthe same time it' <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: I <br /> COMMENTS: HP 5 ?U I <br /> RECEIVED SEP 0 5 <br /> 2 2 201$ 207 <br /> MAR SAN,,oA ENVIRONMENTAL HE;" LTH <br /> ENVI <br /> JOAQUIN <br /> COUNTY �I°'I p R 7 -r <br /> SAN JOAQUIN COUNTY H-EN RON NTAL s ! �� �`{ t <br /> ENVIRONMENTAL H DEPART <br /> HEALTH DEPARTMENT �` <br /> ACCEPTED BY: /�r � EMPLOYEE#: q00 DATE: () .S 1t-1 <br /> ASSIGNED TO: EMPLOYEE#: 3 DATE: (�v;l <br /> . 1"r� <br /> Date Service Completed (if already completed): SEMACE CODE: 16ID$ PIE: (Q% <br /> Fee Amount: Amount Paid L�S6,Q Payment Date �(5 t <br /> Payment Type SA I Invoice# G Check# 1� Received By:L6 <br /> EHD SED 11/1 <br /> "t OSd l� A AC ` 04G-Co Y�1Jden Ro <br /> REVISED 11/1712003 <br />