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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # f n <br /> Gas Station , S �O O <br /> OWNER / OPERATOR !� mm <br /> Mike Ali CHECK If BILLING ADDRE�1 <br /> FACILITY NAME Chevron #103 <br /> SITE ADDRESS 8660 Lower Stockton Rd <br /> Stockton , CA 95210 <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 /> ( ) 925-998-7299 <br /> PHONE #2 916-993-6312 ExT BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> John Baylis CHECK If BILLING ADDRESSE] <br /> BUSINESS NAME PHONE # EXT' <br /> IEC Services 916-993-6312 <br /> HOME or MAILING ADDRESS 4901 Warehouse Way FAX # <br /> CITY Sacramento STATE CA 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 and FEDERAL laws. <br /> APPLICANT'S SIGNATURE : DATE : 6/4/21 <br /> PROPERTY / BUSINESS OWNER ❑ OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT Contractor <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 . <br /> 16 <br /> TYPE OF SERVICE REQUESTED : <br /> COMMENTS : <br /> ACCEPTED BY: EMPLOYEE # : DATE : <br /> ASSIGNED TO : k n , r i EMPLOYEE #: DATE: <br /> Date Service Completed ( if already Completed ) : SERVICE CODE : /t7 Z PIE : 230 <br /> Fee Amount: )NE5za 6 -0 Amount Paid Payment Date <br /> Payment Type Invoice # Check # Received By : <br /> EHD 48-02-025 SR FORM (Golden Rod) <br /> 07/17/08 <br />