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0 0 <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />SERVICE REQUEST # <br />Gas Station <br />f -711 <br />CHECK if BILK. NG ADDRESS <br />OWNER / OPERATOR Mike Gurm <br />EWHO <br />CHECK E] <br />EXT, <br />Elite IV Contractors <br />if BILIJNG ADDRESS <br />FACILITY NAME Hammer Lane Oil <br />461-6337 <br />HOME or MAILING ADDRESS <br />SITE ADDRESS <br />3304 <br />W <br />Hammer Lane <br />3304 W. Hammer Lane <br />Stockton <br />95219 <br />Street Number <br />tion <br />Zip 95205 <br />Street None <br />PIE: <br />cis,Code <br />Amount Paid <br />HOME or MMUNG ADDRESS (If Different from Site Address) <br />Payment Date <br />M <br />Payment Type <br />Invoice # <br />Street Number <br />Che # C6 57 f /06- <br />t Name <br />Cm <br />STATE ZIP <br />PHONE M EXT. <br />APN # <br />LAND USE APPLICATION # <br />( 209 ) 478-9293 <br />PHONE## ExT. <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR Carrie Miller <br />COMMENTS: <br />JAN 19 2016 <br />CHECK if BILK. NG ADDRESS <br />BUSINESS NAME <br />EWHO <br />PHONE# <br />EXT, <br />Elite IV Contractors <br />1209 <br />461-6337 <br />HOME or MAILING ADDRESS <br />FAX# <br />DATE: I C1 I <br />3304 W. Hammer Lane <br />( 209) <br />461-6342 <br />CITY Stockton <br />STATE CA <br />Zip 95205 <br />BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br />acknowledge that all site and/or prt?ject 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: e"� 7 t, DATE: 1118116 <br />PROPERTY/BUsmEssOwNER❑ OPERATOR/ MANAGER Q OTHER AUTHORIZED AGENT® Office Manager <br />If Al'I'MCANT is not the BILLING PARTY, proof of authorization to sign is required Title <br />AUTHORIZATION TO RELEASE IN11FORMATION: 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 environmenial!)s feG <br />Tent, <br />information to the SAN JOAQUIN COUNTY ENviRONMENTAL HEALTH DEPARTMENT as soon as it is available and a t14'� ItIFil <br />provided to me or my representative. P em' <br />TYPE OF SERVICE REQUESTED: Repair Diesel Product Line Flex Connector RECefy <br />COMMENTS: <br />JAN 19 2016 <br />�F�°RONM <br />EWHO <br />EALTFI pFp��ll. <br />ACCEPTED BY: <br />EMPLOYEE #: <br />DATE: I C1 I <br />ASSIGNED TO: <br />EMPLOYEE M <br />DATE: I <br />Date Service Completed (If already completed): <br />SERVICE CODE: 5G <br />PIE: <br />Fee Amount: <br />Amount Paid <br />3170, D <br />Payment Date <br />M <br />Payment Type <br />Invoice # <br />Che # C6 57 f /06- <br />Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11117/2003 <br />2016 <br />IETAL <br />4'1TI;,"rq��r <br />