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RECEIVED <br /> AUG 24 2016 <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST ENVIRONMENTAL <br /> Type of Business or Property FACILITY ID# SERVI ENT <br /> Gas Station F �0��.` �� '�)C— 00-)059/ <br /> OWNER/OPERATOR <br /> Quick Stop Markets Inc CHECK if BILLING ADDRESS <br /> FACILITY NAME Quick Stop 138 <br /> SITE ADDRESS 1153 Lincoln Blvd Tracy 95376 <br /> Street Number I Direction I Street Name City zip C040 <br /> HOME or MAILING ADDRESS (If Different from Site Address) 4567 Enterprise Sreet <br /> Street Number Street Name <br /> CITY Fremont STATE Ca ZIP 94538 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> ( 209) 835-8284 J 1 190 I -'), <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> - ( 800) 972-0982 11 <br /> CONTRACTOR It SERVICE REQUESTOR <br /> REoUESTOR Megan Mitchell <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME Elite IV Contractors PHONE# EXT. <br /> 209 461-6337 <br /> HOME or MAILING ADDRESS 2535 Wigwam Dr FAx# <br /> (209) 461-6342 <br /> CITY Stockton STATE Ca zIP 95205 <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 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 /> /� <br /> APPLICANT'S SIGNATURE: ��GaC!�/J:Q.� DATE: L9/24/9016 <br /> PROPERTY/BUSINESSOWNER❑ OPERATOR MANAGER ❑ OTHER AUTHORIZED AGENT IR Office Assistant <br /> IfAPPLICANT 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 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: Replaced 89 STP 208 Sensor pAYIV rrr <br /> COMMENTS: �� TEC <br /> 'Vi/ <br /> a%'/04Q4/,A,4 ?ops <br /> kyr ' <br /> H�1�o�aMRk(o�MY <br /> MFti'T <br /> ACCEPTED BY: EMPLOYEE#: DATE: Cjr - l <br /> 1 <br /> ASSIGNED TO: n C � EMPLOYEE#: DATE: - )-L - / <br /> c <br /> Date Service Completed (if already c pleted): 8/24/20`16 SERVICE CODE: f C, PIE: 3C <br /> c <br /> Fee Amount: VI �L� Amount Pa 17- bO Payment Date $Z <br /> Payment Type Invoice# C ck# (P/ a2 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />