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0 <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />Eric Janzen CHECK If BILLING ADDRESS <br />SERVICE REQUEST # <br />Gasoline Service Station <br />3(� 02— <br />RECEIVED <br />5/Z 0() " 574 <br />OWNER /OPERATOR <br />HOME or MAILING ADDRESS <br />FAX # 707 545-5515 <br />Tesoro Refining & Marketing <br />CHECK if BILLING ADDRESS <br />FACILITY NAME <br />CITY <br />Santa Rosa CA 95403 STATE ZIP <br />ACCEPTED BY: � <br />Shell #68151 <br />SITE ADDRESS 35 <br />N <br />Cherokee Lane <br />Lodi <br />95240 <br />Street Number <br />Direction <br />Street Name <br />0 <br />city <br />Zip Code <br />HOME Or MAILING ADDRESS (If Different from Site Address) <br />Payment Type �', <br />Invoice # <br />Street Number <br />I n,`) <br />Street Name <br />CITY <br />STATE ZIP <br />same as above <br />PHONE #t EXT. <br />APN # <br />LAND USE APPLICATION # <br />( ) <br />043-180-03 <br />PHONE #I EXT• <br />( 1 <br />BIDS DISTRICT -7 <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />Eric Janzen CHECK If BILLING ADDRESS <br />BUSINESS NAME <br />PHONE# 707 293-29dxT <br />RECEIVED <br />Able Maintenance, Inc. <br />11 <br />HOME or MAILING ADDRESS <br />FAX # 707 545-5515 <br />SAN JOAMUFN COUNTY <br />3224 Regional Parkway <br />( ) <br />CITY <br />Santa Rosa CA 95403 STATE ZIP <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 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 witha1�AN JOAQUIN <br />COUNTY Ordinance Codes, Standards, STATE and FEDERAaws. <br />APPLICANT'S SIGNATU — _ DATE: —20 <br />PROPERTY / BUSINESS OWNER❑ OPERAT OTHER AUTHORIZED AGENT C+ a CO pliance Officer <br />If APPLICANT is not the BILLING PAR p oof of authorization 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 SERVICE REQUESTED:T— <br />COMMENTS: <br />PAYMENT <br />RECEIVED <br />MAR 19 2012 <br />SAN JOAMUFN COUNTY <br />EWRONMENTAL <br />ACCEPTED BY: � <br />EMPLOYEE #: C, C) <br />ASSIGNED TO: CIA11-- Az (.F <br />EMPLOYEE #: 1422- <br />DATE: v7 1 <br />12— <br />ZDate <br />Date Service Completed (if already completed): <br />SERVICE CODE: 1 q <br />P / E: <br />0 <br />Fee Amount:Amount <br />Paid I?, <br />Payment Date 7 <br />1 �-.-- <br />Payment Type �', <br />Invoice # <br />Check # ii? <br />I n,`) <br />Received By: <br />�r <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />