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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> 3FC?W1U` VlEOUEST <br /> Type of Business or Property FACILITY ID # SERVICE REQUEST # <br /> OWNER / OPERATOR <br /> Paul Judge CHECKif BILLING ADDRESS ® <br /> FACILITY NAME <br /> Chevron <br /> SITEADDRESS 437 N Wilson Way Stockton <br /> 95205 <br /> Street Number Direc ion Street Name City Zi Coda <br /> HOME or MAILING ADDRESS ( If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE #1 ExT. APN # LAND USE APPLICATION # <br /> ( 20 942-2344 <br /> PHONE #2 ExT• BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> Megan Mitchell CHECK if BILLING ADDRESSID <br /> BUSINESS NAME PHONE III ExT, <br /> Elite IV Contractors ( 209 461m6337 <br /> HOME or MAILING ADDRESS FAX # <br /> 2535 Wigwam Dr ( 209 461 - 6342 <br /> CITY Stockton STATE Ca 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 or <br /> 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 : i`G� DATE : v I 1 `% <br /> PROPERTY / BUSINESS OWNER ❑ OPERATOR / ANAGER ❑ OTHER AUTHORIZED AGENT l 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 , 1 , the owner or operator of the property located at the above <br /> site address , hereby authorize the release of any and all results , geotechnical data and/or environmental/site assessmenti emation <br /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It i5 available and at the Same time it Is provldt <br /> my representative . Sol <br /> TYPE OF SERVICE REQUESTED : u t t� � <br /> COMMENTS : ell <br /> q� d0 <br /> 14 try '(wil�ROTq QTY <br /> RTM <br /> ACCEPTED BY : n ��1/ EMPLOYEE #: % DATE: Ir/ <br /> ASSIGNED TO : `+ 1eL�re EMPLOYEE #: / DATE: <br /> Date Service Completed (if already completed ) : ---- SERVICE CODE : PIE: 2,30r <br /> Fee Amount : ,// dl ' Amount Pai �, �� Payment Date ) 2 l <br /> Payment Type S� Invoice # Check # ) b 2.jogdC>A-J ' Received By: <br /> EHD 48-02-025 SR FORM (Golden Rod) <br /> 07/17/08 <br />