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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 />SERVICE REQUEST # <br />Gas Station <br />ACCEPTED BY: le -44 <br />C{ <br />OWNER i OPERATOR <br />DATE: �1 2 Ll <br />I <br />PHONE # <br />EXT. <br />CHECK If BILLING ADDRESS <br />FACILITY NAME <br />09 <br />461-6337 <br />Two Guvs <br />Fee Amount: 2�c1 O`; <br />FAX# <br />SITE ADDRESS <br />2535 Wigwam drive <br />Payment Type <br />(209) <br />461-6342 <br />CITY Stockton <br />1 dd ''77 � <br />j� <br />Lathrop RredetName <br />LathroI p <br />9i Codec <br />StleetNumber Direction' <br />HOME Or MAILING ADDRESS (If Different from Site Address) <br />Street Number <br />Street Name <br />CITY <br />STATE zip <br />PHONE #i ExT. <br />APN # <br />LAND USE APPLICATION # <br />( 2091 858-2666 <br />PHONE #2 EXT. <br />( ) <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQU ESTOR <br />COMMENTS: <br />Jeanie Webb <br />ACCEPTED BY: le -44 <br />r • � CHECK if BILLING ADDRESS <br />BUSINESS NAME <br />DATE: �1 2 Ll <br />I <br />PHONE # <br />EXT. <br />, <br />DATE: It L U7 <br />09 <br />461-6337 <br />HOME or MAILING ADDRESS <br />Fee Amount: 2�c1 O`; <br />FAX# <br />2535 Wigwam drive <br />Payment Type <br />(209) <br />461-6342 <br />CITY Stockton <br />STATE CA <br />ZIP 95205 <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 with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, STATE and FEDERAL laws. <br />APPLICANT'S SIGNATURE: <br />PROPERTY/ BUSINESS OWNER❑ <br />DATE: 11-18-2004 <br />OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT ® Parts <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 environmentaUsite assessment <br />information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and j I and 91hp—same time it is <br />provided to me or my representative. <br />TYPE OF SERVICE REQUESTED: CX S % F t T <br />COMMENTS: <br />Nov 2 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />l FALTH DEPARTMENT <br />ACCEPTED BY: le -44 <br />EMPLOYEE #: <br />j _ / <br />DATE: �1 2 Ll <br />I <br />ASSIGNED TO: v/unJ F U C <br />EMPLOYEE #: <br />, <br />DATE: It L U7 <br />Date Service Completed (if already completed): <br />SERVICE CODE: <br />P I E: �J • -5 <br />Fee Amount: 2�c1 O`; <br />Amount Paid 1 9117-r-0 <br />Payment Date <br />Payment Type <br />Invoice # I <br />Check # 9 <br />Received By f <br />EHD 48-02-025 <br />REVISED 11/17/2003 <br />SR FORM (Golden Rod) <br />