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SAN JOAQUOOUNTY ENVIRONMENTAL HEALTH OARTMENT <br /> ` SERVICE REQUEST <br /> t Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> &asoline Station 600 0 L(c-f <br /> OWNER/OPERATOR <br /> CHEVRON Fr5puar!; Co. CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> SITEADDRESS33S`J �7mw+et- �-�nc� Sfin�kfioC1 o(tj212 <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#t EXT. APN# LAND USE APPLICATION# <br /> PHONE#Z EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> / SERVICE REQUESTOR <br /> REQUESTOR Aa• z • Proj. Mgr. CHECK If BILLING ADDRESS <br /> Ca�aninb , <br /> BUSINESS NAMEPHONE# <br /> _ 914L Design 'buP lne• _(°IZS) 315 41100 <br /> Ib� <br /> HOME Or MAILING/ADDRESS FAX# <br /> 134v Arnold Drive Suite (a25) 313 <br /> CITY 11artin�i G1 <br /> STATE CA ZIP 4 <br /> BILLING ACKNOWLEDGEMENT I, the undersigned property or business owner, operator o authori_zled 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: ;x - Z1 - 04' <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR MANAGER ❑ OTHER AUTHORIZED AGENT 9 �f�ex-+ H V OICC <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: Repair Retr0Tr!l1 <br /> Plan GhGGk CE�vED <br /> COMMENTS: plan Check -Fc,r 5P1,11 CDntainmar%t (G�al7cet+r►C1►'�'. t,` Q 2004 <br /> SAN JOA COUNTY <br /> HEALTH DEPARTMENOIAL T <br /> ACCEPTED BY: r ` Imo^ EMPLOYEE#: 3 DATE: : --7 OC� <br /> ASSIGNED TO: EMPLOYEE#: 3 5 DATE: -712-1 0" <br /> Date Service Completed (if already completed): SERVICE CODE: t P/E: 23O� <br /> Fee Amount: Z Gi , 670 Amount Paid 0-7e). <br /> -7e), (:20 Payment Date Z � L/ <br /> Payment Type invoice# Check# p Received By: ., <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />