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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # SERVICE REQUEST # <br /> Gas Station � � SQ <br /> OWNER / OPERATOR <br /> CHECK If BILLING ADDRESS <br /> Love reet Sher ill <br /> FACILITY NAME <br /> Bill.jar Valero <br /> SITE ADDRESS E 11 th Street Tracy 95376 <br /> 153 M Street Number Wectlon Street Name city Zip Code <br /> HOME or MAILING ADDRESS (if Different from Site Address) <br /> same as above Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE #1 EXT, APN # LAND USE APPLICATION # <br /> ( 209 ) 832-8815 <br /> PHONE #2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR CHECK If BILLING ADDRESS <br /> Deborah Jones <br /> BUSINESS NAME PHONE # ExT' <br /> Elite IV Contractors 209 461 =6337 <br /> HOME or MAILING ADDRESS FAX # <br /> 2535 Womam Nye <br /> l ) <br /> ITY S��TATE ZIP <br /> tockton�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 FEDERAL laws. <br /> APPLICANT'S SIGNATDATE : 1 /25/2021 <br /> PROPERTY / BUSINESS OwNER ❑ OPERATOR / A CER 13 OTHER AUTHORIzEDAGENT ® Administrative Assistant <br /> If APPLICANT is not the BILLING PAR , 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 atld at the same time it is <br /> provided to me or my representative. /YFry <br /> TYPE OF SERVICE REQUESTED : f j t C <br /> COMMENTS : <br /> SO4 IV JAN 26 2021 <br /> EN�AQU/N C <br /> NEA � Ty�EpMEN q�NTy <br /> q RTMEN <br /> ACCEPTED BY: �l EMPLOYEE # : DATE: I ! c <br /> ASSIGNED TO : Sj,� � � 'SSS '� EMPLOYEE #: DATE : z� <br /> Date Service Completed (if already completed) : SERVICE CODE : q , <br /> PIE : <br /> WERE <br /> Fee Amount: %0 �� 470 Amount Pal f D Payment Date u Z <br /> Payment Type < , invoice # Check # 7� zv Recei ed Bye <br /> EHD 48-02-025 SR FORM (Golden Rod) <br /> REVISED 11 /17/2003 <br /> I <br />