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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # SERVICE REQUEST # <br /> RETAIL GAS STATION o � � L L4 <br /> OWNER / OPERATOR PAUL TREHALA <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME SINCLAIR/AJ ' S MINI MART <br /> SITE ADDRESS 7906 N EL DORADO STREET STOCKTON 95210 <br /> Street Number Direction I 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 F APN # LAND USE APPLICATION # <br /> ( 209 ) 957-2987 <br /> PHONE #2 EXT. BOS DISTRICT LOCATION CODE <br /> ( 209 ) 957-3628 <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR ANDREA HOCKENBERRY CHECK If BILLING ADDRESS ® <br /> BUSINESS NAMETANK-TIGHT SYSTEMS , INC PHONE # EXT. <br /> 916 667 -6891 <br /> HOME or MAILING ADDRESS FAX # <br /> 8515 WATERMAN ROAD ( ) <br /> CITY ELK GROVE STATE CA ZIP 95624 <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 ; 11 /28/2021 <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 /> TYPE OF SERVICE REQUESTED : ,SS TOt R <br /> COMMENTS : ` D <br /> sAN oeT 28 2021 <br /> HRA TH 1)NMRN�UNTY <br /> ART C <br /> ACCEPTED BY: f �� EMPLOYEE # : DATE : <br /> ASSIGNED TO : V J `y� EMPLOYEE # : DATE: Erg � <br /> Date Service Completed ( if already completed) : / SERVICE CODE : / q � O / p PIE : ,20()�, <br /> Fee Amount: Amount Paid C .L J Payment Date <br /> Payment Type Invoice # Check # 1 3 2 Received By : <br /> EHD 48-02-025 SR FORM (Golden Rod) <br /> 07/17/08 <br />