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SAN JOAQUII-OUNTY ENVIRONMENTAL HEAI.TOEPARTMENT <br />Type of Business or Property <br />GAS STATION <br />(-)-VNAI /.. <br />f-- <br />1 f �cUTY V;,M <br />SERVICE REQUEST <br />I { OR i � w, &M, & phytIll <br />FACILITY ID # <br />A-p0UIS7o <br />SERVICE REQUEST # <br />CHECK if BILLING ADDRESS LJ i <br />�74mM <br />I Sheet Number I Direction Za-a. Ziw. C':,de —_ <br />HUM,E 0' MAlUNG ADDRESS (if Different fro;ddress) <br />_ Street Number 1 Street Name <br />d <br />CITY ---- — STATE ZIP <br />PHONE :Y7 Ext_ APN # LAND USE FdF'P2.RL'ATION # — <br />_ _ <br />PHONE 1`2 EXT. _ EiUr ':-ISTRICs ' .00ATION C['..: <br />jJ <br />74�--�--- <br />_ C0NTRACT0R j;',9. 1', It CF <br />TV CONTRACTORS, INC, <br />HOME 01' MAILING ADDRESS <br />2535 WIGWAM DRIVE <br />CITY <br />STOCKTON <br />RE.QU �SIi - <br />CHECK if i iLLiNG ADDSE--,)V,! <br />, <br />_ --- - -1 PHaNE # <br />—._.. I_ ( `Zi ) 461-633 + i <br />Fax !I <br />(209)461-6342 <br />STATE CA ZIP 95205 <br />TILLING ACKNOWLEDGEMENT: I, the undersigned pro-.crty m business owner, eperator or authorized agent of sail e. <br />that all site :-il,ur project specific ENVIRONMENTAL ITFALTII DEPARTMENTi �,,rly 01p ,jrgeS associated with this proi:xt Dr <br />-tivity will be billed nr, hnaness as identified on this form. <br />i a'so certify that I hz:: pre'na-ed this application and that the work to be performed will be dine. it accordance witf-i '01 SAN 1oAQU+n' <br />COUN'•'Y O:-diat-ce Codes, Standards, ,TATE and FEDERAL laws. <br />4PPLI(. ANT'S SIGNATURE: / ( _ _ DATr: <br />PROPERTY / BUSINESS OWNF-k -- OPERATOR/ MANAGER ❑ O':IIER AUTIIORIZED AGENT d��.� <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 siie address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br />informatioh 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. ..r-t1IT <br />TYPE OF SERVICE REQUESTED: L•17� '� <br />;}' G��vED <br />COMMENTS: <br />``� <br />O�J <br />GO NN <br />SAS d0A pNMEN! <br />Ham, fH pEPPRlM <br />APPROV _. Y: I <br />EMPLOYEE #:r7 c` Xj <br />DATE: <br />ASSIGNED TO: P % <br />EMPLOYEE #: r y` !j <br />DATE: 11 JI .— �,� 0 - <br />Date Service Completed (if already completed): <br />SERVICE CODE: j �� ` <br />P 1 E -7,, <br />Fee Amount: C <br />Amount Paid -I <br />Payment Date <br />Payment Type ,o- <br />Invoice # <br />Check # —7-7!- <br />Received By: <br />EHD 48-01-025 <br />RGv1cFn a_r-nq <br />SERVICE REQUEST FOR <br />