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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> SERVICE REQUEST # <br /> FACILITY ID # <br /> i <br /> Type of Business or Property F <br /> Fuel dispensing station- - � - - 0 0 5b . INN <br /> . 7 <br /> OWNER I OPERATOR CHECK if BtLL!NG AODRESB ® <br /> FACILITY NAME <br /> George Kishida <br /> S(TeADDRESS Ackerman Drive Lodi <br /> 1725street Number <br /> Direction StreetNelms ch) <br /> 2 ' Cr, sc <br /> HoME or MAILING ADDRESS (if pifferent from Site Address) _ <br /> `�e"E✓l �,_.._.. straniNumbsr - Street.Nar e . <br /> CITY STATE ZIP <br /> PHONE #1 k: t qi?N # LANq Use APPL:IcAmoN # <br /> ( 2OS ) 36$-0603 <br /> PHONE #2 Bl� i3l5TRICT LOCATION CDDE <br /> t } ' <br /> CONTRACTOR 1 SERVICEREQUESTO►R. nn <br /> REQUESTOR CHECK If BILLING A0DRW3 <br /> Emily Crain 111 <br /> PHONE * � . <br /> BUSINESS NAME <br /> 8Z Maintenance 916 371 -2380 <br /> FAX # <br /> HOME Or MAILING ADDRESS <br /> PO Box 933 ( ) <br /> rmITY <br /> STATECA <br /> ZIPe; Sauamenta <br /> £TILLING ACI NOWLEDGEME1.T; i, the undersigned prop" or business owner, operat©r or authorized agent of same , <br /> acknowledge that all site and/or project ' specffiG 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 Godes, Standards; . STATE and;.FEoE0 laws: ' <br /> APPL1CAi+IT' SIGNATURE : ; . GAtIE ; _ l <br /> IFPROPERTY I BUSINESS OWNER Ed 6PERATORI MANAGER ❑ OTHER ALITHoRlzg + Ar*ENT ❑ <br /> It .Appoc.ANT is not the g LAA PAR7Y, proof of authorization to sign is l'equlrod Tit]e <br /> ALITHORIZATION TO RELEA3'E !NFORMATICJN ; When applicable , i , the owner or Operator OfN the property located at the above <br /> site address , hereby authorize the release of any and all results, geotechn pad 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.ti <br /> r e it is provided to me or <br /> my representative. rh+' <br /> TYPE OF SERVICE REQUESTED U <br /> COMMENTS; JU <br /> N All <br /> SAQ2 ?QZ <br /> ,Jpq � <br /> HEq TN Do AMEN AUFNTY <br /> ARTM <br /> ACCEPTED BY: EAAPLOYSE # DATE: Z- ZDZ <br /> As8lGNED TO: v . 1 eOoo 7 EMPLOYEE #4 Q DAATTE: . 2 <br /> Date $ervico Completed (If a early completed): SERVICIICone; 1 G� 0 ' q O PIE* <br /> 2 <br /> Fee Amount; O Amount Pat m . 77TT <br /> F'ayr> tent Date Z <br /> payment Type Invoice # Check # - Rene v® sy; <br /> 33 a <br /> EHD 48-02-028 SR FORM (Golden Rod) <br /> 47117/08 <br />