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SAN JOAQUIN COUNTY ENV ~"� ARTMENT SERV Type of Business or Property F I TY� DX015 SERVICE REQUEST # GAS STATION Ad LJ OWNER/ OPERATOR EE V V IPl E] ADDRESS❑ or Saad I jcC, -r,,-r-OAO—T,4r-�,i, CHECK if BILLING FACILITY NAME EMPLOYEE #: 2535 Wigwam Dr. 24 HOUR GAS & MART (209 ) 461-6342 SITE ADDRESS STATE CA ZIP 95205 P i E: Fee Amount: ! LUL, Amount Pai 3 l d DO Payment Date 1901 Street Number I DIAtlon I EL DORADO Street a e C ck # 5(16 STOCKo ON Zio Code HOME or MAILING ADDRESS (If Different from Site Address) Street Number Street Name CITY STATE ZIP PHONE #1 EXT. APIN # LAND USE APPLICATION # (209 ) 954-2709 PHONE #2 EXT. BOS DISTRICT 11 LOCATION CODE 1 ( 209) 207-1252 CONTRACTOR / SERVICE REQUESTOR REQUESTOR qY CHECK if BILLING ADDRESS Carrie Miller BUSINESS NAME Elite IV Contractors PHONE# 20 EXT. 461-6337 HOME or MAILING ADDRESS FAX # EMPLOYEE #: 2535 Wigwam Dr. ASSIGNED TO:'"-, (209 ) 461-6342 CITY Stockton STATE CA ZIP 95205 BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project specific ENVIRONMENTAI. HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as identified on this form. I also certify that I have prepared this a lication and that the work to beip formed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, Standards TATE and FEDERAL la s' t r � APPLICANT'S SIGNATURE: ] 5 { {� t j ( .;t, DATE: f(( l PROPERTY / BUSINESS OWNER❑ VPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT Office Manager If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required Title AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTIi DEPARTMENT as soon as it is available and at the Same time it is provided to me or my representative. TYPE OF SERVICE REQUESTED: 91 LD AND FILL BUCKET REPLACEMENT qY COMMENTS: ACCEPTED BY: rYl I l/^ EMPLOYEE #: DATE: ASSIGNED TO:'"-, EMPLOYEE #: DATE: Date Service Completed (if already Completed): SERVICE CODE: C P i E: Fee Amount: ! LUL, Amount Pai 3 l d DO Payment Date 7 !� Payment Type �� Invoice # C ck # 5(16 Received By: EHD 48-02-025 REVISED 11/17/2003 i SR FORM (Golden Rod) SIS