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ML(;WVtU NOV O6 2015 SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT AL SERVICE REQUEST NVIRONufTAI-rUnCN�EN NT Type of Business or Property FACILITY ID # EMPLOYEE #: SERVICE REQUEST # Gas Station Min Mart L00CM'39-0077�"�SOWNER EMPLOYEE #: PHONE # /OPERATOR CHECK If Quik Stop Markets BILLING ADDRESS❑ FACILITY NAME HOME or MAILING ADDRESS 2535 Wigwam Dr. Quik Stop #121 FAX SITE ADDRESS Check # Received By: %6 ( 209 ) CITY Stockton 1196 VV Louise Ave. TManteca ' T Street Number Dimuors Street Name Code HOME or MAILING ADDRESS (If Different from Site Address) street Number Street Name CITY STATE ZIP PHONE #1 ExT. APN # LAND USE APPLICATION # ( 209) 239-2957 o PHONE #2 EXT. SOS DISTRICL LOCATION ODE ( ) CONTRACTOR / SERVICE REQUESTOR REQUESTOR Carrie Miller EMPLOYEE #: CHECK If BILLINGADDREJ3 BUSINESS NAME EMPLOYEE #: PHONE # EXT. Elite IV Contractors P! E: 20 461-6337 HOME or MAILING ADDRESS 2535 Wigwam Dr. Payment Date ( 0 9 i S FAX 461-6342 Check # Received By: %6 ( 209 ) 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 ENVIRONMENTAL 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 application and that the work to be performed will be done in accordance with 0 SAN JOAQUIN COUNTY Ordinance Codes, Standards, STATE and FEDERALlaws. APPLICANT'S SIGNATURE: C444-e�l W�`�'�- DATE: 11/6/15 PROPERTY / BUSINESS OWNER❑ OPERATOR / MANAGER ❑ OTHER AUTHOWED AGENT [�k Office Manager If APPLICANT is not the BILLING PARTY proof of audsorizadon to sign is required Title AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, 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 to the SAN JOAQUIN COIJNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. TYPE OF SERVICE REQUESTED: Replaced 87 LD COMMENTS: NOV 092 15 SAN JOAQUIN C UI ENVIROMEN HEALTH DEPARTme ACCEPTED BY: bom EMPLOYEE #: DATE: / S ASSIGNED TO: Z U EMPLOYEE #: DATE: t Date Service Completed (if already completed): SERVICE CODE: M P! E: Fee Amount: O L { I Amount Paid Payment Date ( 0 9 i S Payment Type Invoice # Check # Received By: %6 EHD 48-02-025 elf"' *- -71 s O 7 3 SR FORM (Golden Rai) REVISED 11/17=03 d_tt(A- ( I/1,/ j6-- .