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0 0 <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# c SERVICE REQUEST# <br /> Gas Station FAM a 3 ✓'� �?�� <br /> OWNER/OPERATOR <br /> Kevin CHECK It BILLING ADDRESS <br /> FACILITY NAME Gas Depot <br /> SITE ADDRESS 1330 E Yosemite AveManteca 95336 <br /> Street Numbor Ir n t e Cit Zi Cod <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 ) 825-0332 1 D'21:;Lob 45-'-5 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR Megan Mitchell CHECK If BILLING ADDRESS® <br /> BLISINESS NAMEPHD2N # EXT. <br /> Elite IV Contractors 9 461-6337 <br /> HOME Or MAILING ADDRESS 5235 Wigwam Dr ( 209 ) 461-6342 <br /> CITY Stockton STATE Ca ZIP 96205 <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 tome or my business as identified on this for . <br /> 1 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,Slandard,STAan FEDERAL laws. <br /> APPLICANT'S SIGNATURE E: 5/8/2017 <br /> PROPERTY/BusINESs OwNER 130RAT R/MANAG R ❑ tE uTHOR(7,ED AGENT Q Office Assistant <br /> jf APPLICANT is nol the BI , G PARTY proof ofauthorizVlon 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 S l tbISTED; L4 6 <br /> C0MMENTS:RE,G'1 a <br /> sx JOAQNim `;nh <br /> ACCEPTED BY: 5 EMPLOYEE M DATE: <br /> ASSIGNED TO: 0A9122 1EMPLOYEE M DATE: <br /> .0111C <br /> Date Service Completed (If already completed): SERVICE CODE: P 1 . <br /> Fee Amount: �Ajeu Amount Pal 1�7,�� Payment Date ,s 4 <br /> Payment Type (�`.- Invoice# Ch k 0 gob Rec ed By: <br /> EHD 48.02.025 SR FORM(Golden Rod) <br /> REVISED 11117/2003 <br />