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SAN.JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE <br /> EE7REQUEEST# <br /> �e6 /7� <br /> Gas Station Fq-c a L//5' <br /> OWNER I OPERATOR <br /> Kevin CHECK If BILLING ADDRESS <br /> FACILITY NAME Gas Depot <br /> SITE ADDRESS 1330 E Yosemite Ave Manteca 95336 <br /> Street Number Irectlon Street Name cityP Code <br /> HOME or MAILING ADDRESS (if Different from Site Address) <br /> Street Number street Name <br /> CITY STATE ZIP <br /> PRONE#1 Exr. APN# LAND USE APPLICATION# <br /> (209 ) 825-0332 1 D-21 45 --5 <br /> PHONE 92 ExT• BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR Megan Mitchell ! <br /> CHECK If LING ADDRESS <br /> BUSINESS NAME Elite IV Contractors ( 2O9 461-6337 En. <br /> HOME or MAILING ADDRESS 5235 Wigwam Dr FAx# <br /> ( 209 ) 461-6342 <br /> 7 <br /> CITY Stockton STATE Ca LP 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 tome or my business as identified on this for <br /> I also certify that I have prepared this application and that the work o be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standard,STA an FEDERAL laws. <br /> APPLICANT'S SIGNATUREJ 5/8/2017 <br /> PROPERTY/BUSINESS OWNER❑ -JVOQRATR/MANAG R ❑ E AUTHORIZED AGENT Q Office Assistant <br /> IJAPPLICANT is not the BPARTY,proof of authoriz ton 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 available and at the same time it is <br /> provided to me or my representative. <br /> TYPE OF SftdIL�STED: j f. <br /> % I I D <br /> COMMENTS:R ECEI <br /> SIA <br /> yiEAL1 +REPAY Pry¢"' Cr ;�H <br /> ACCEPTED BY: y/.L G EMPLOYEE#: DATE: n <br /> ASSIGNED TO: '/✓ / EMPLOYEE M DATE: <br /> c <br /> Date Service Completed (If already completed): SERVICE CODE: P 1 . <br /> Fee Amount: GC`s Amount Pal [�7,�� Payment Date S g <br /> Payment Type Invoice# Ch k# 7 g�� Rec ed By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />