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• <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 />( E# <br />�1�9 <br />� "" <br />SIR ct )` 4j C1 /V <br />OWNER / OPERATOR <br />Harry <br />FAX # <br />( 209 ) <br />461-6342 <br />CITY Stockton <br />STATE Ca <br />CHECK if BILLING ADDRESS <br />FACILITY NAME Harry's One Stop Market <br />SITEADDRESS 1151 <br />WLouise <br />Ave <br />EMPLOYEE #: <br />Manteca <br />95336 <br />Street Number <br />c <br />EMPLOYEE M <br />DATE: T 2 <br />cit <br />Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />� g <br />PIE: Z 3C044 <br />Fee Amount: 6 2S Amount Pald <br />— <br />Payment Date <br />Street Number <br />Invoice # <br />Street Name <br />CITY <br />STATE ZIP <br />PHONE #1 ExT• <br />APN # <br />LAND USE APPLICATION # <br />( 209 ) 823-4081 <br />4- 0o I <br />PHONE #2 ExT• <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR Megan Mitchell <br />CHECK If BILLING ADDRESS® <br />BUSINESS NAME Elite IV Contractors <br />( E# <br />�1�9 <br />Exr. <br />1-6337 <br />HoM£ or MAILING ADDRESS 2535 Wigwam Dr <br />48', <br />FAX # <br />( 209 ) <br />461-6342 <br />CITY Stockton <br />STATE Ca <br />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 RAL laws. <br />APPLICANT'S SIGNATURE: "� DATE: 14-1,01-14 <br />PROPERTY / BUSINESS OWNER❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZE.DAGENT ® Office Assistant <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 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. PA <br />TYPE OF SERVICE REQUESTED: <br />RFc FNT <br />COMMENTS: <br />S� ®?�1 <br />48', <br />�P,y •� <br />� of %� <br />ACCEPTED BY: <br />EMPLOYEE #: <br />DATE: <br />ASSIGNED TO: <br />EMPLOYEE M <br />DATE: T 2 <br />Date Service Completed (if already completed): <br />SERVICE CODE:' n <br />� g <br />PIE: Z 3C044 <br />Fee Amount: 6 2S Amount Pald <br />� � <br />Payment Date <br />Payment Type <br />Invoice # <br />Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11117/2003 <br />