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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY IDD# SERVICE REQUEST # <br /> Gas Station F'fo 02,4 O S kooV� a <br /> OWNER If OPERATOR <br /> Sean Murphy CHECK If BILLING ADDRESS <br /> FACILITY NAME ARCO <br /> SITE ADDRESS 6009N EI Dorado Street Stockton 95207 <br /> Street Number Direction Street Name City Zip Code <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 /> ( ) <br /> PHONE #2 ExT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR John Baylis X <br /> CHECK If BILLING ADDR S <br /> BUSINESS NAME IEC Services PHONE # ExT. <br /> 9161 993-6312 <br /> HOME or MAILING ADDRESS 4901 Warehouse Way, Sacramento , CA 95826 FAX # <br /> CITY STATE ZIP 95826 <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 <br /> andFEDER� AALL laws . <br /> 9&16foo <br /> APPLICANT' S SIGNATURE : 5a3 DATE : 7/9/21 <br /> PROPERTY / BUSINESS OWNER ❑ OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT Ca Manager <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 above <br /> site address , hereby authorize the release of any and all results , geotechnical data and/or environmental/site assessment information <br /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the same time It Is provided to me Or <br /> my representative . PA ve . <br /> TYPE OF SERVICE REQUESTED : 6Ln , T <br /> COMMENTS : D <br /> sqN It 3 ?021 <br /> EN �gQU/N CO <br /> HFgLT!Rp P rATY <br /> ACCEPTED BY: NVQ . EMPLOYEE #: DATE : rL J <br /> ASSIGNED TO : ` EMPLOYEE # : DATE : <br /> Date Service Completed ( if already completed) : SERVICE CODE : / ollr � 2qp PI Ea., <br /> '2 <br /> Fee Amount: / �� aU Amount Pal �� ` vc� Payment Dateyr <br /> Payment Type G� Invoice # Check # IL� Z Received By : <br /> EHD 48-02-025 SR FORM (Golden Rod) <br /> 07/17/08 <br />