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SAN JOAQUI*UNTY ENVIRONMENTAL HEALTH WARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY l6# SERVICE REQUEST# <br /> COMMERCIAL <br /> OWNER/OPERATOR <br /> SATINDER DILAWRI CHECK If BILLING ADDRESS <br /> FACILITY NAME SAVE ON GAS (FORMER RAINWATER CAR WASH) <br /> SITE ADDRESS 420 WEST YOSEMITE AVENUE MANTECA 95337 <br /> Street Number I Direction I Street Name city Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> RXEIVEDSTATE ZIP <br /> pW 118 2013 Ezr. APN# LAND USE APPLICATION# <br /> 219-312-06 <br /> ENV AL HEALTH Ext. BOS DISTRICT LDDATION CODE <br /> FHRMIT/$ERUICFS <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR ADVANCED GEOENVIRONMENTAL, INC <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> ADVANCED GEOENVIRONMENTAL, INC 209 467-1006 <br /> HOME or MAILING ADDRESS FAx# <br /> 837 SHAW ROAD ( ) <br /> CITY STOCKTON STATE CA Zip 95215 <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 TATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: �� aal A DATE: 16 APRIL 2018 <br /> PROPERTY/BUSINESSOWNER❑ OPERATOR/MANAGER ❑ OTHERAUTHORIZEDAGENTM STAFF GEOLOGIST <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. <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P/E: <br /> Fee Amount: Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />