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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 S(� � qSJ <br /> OWNER / OPERATOR <br /> Aasim Enterprises CHECK If BILLING ADDRESS <br /> FACILITY NAME Chevron #60 Stockton <br /> SITE ADDRESS 10878 North Hwy 99 Stockton 95212 <br /> Street Number Direction I Street Name Citv 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 /> ( ) 707-486-8894 � OD 2D <br /> PHONE #2 Ex-r. <br /> �' `"' BOS DISTRICT OCAT NODE <br /> ( ) 209-931 -6154 � � y <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR John Baylis CHECK if BILLING ADDRESSLX <br /> BUSINESS NAME IEC Services PHONE # EXT. <br /> 916- 993 -6312 <br /> HOME or MAILING ADDRESS FAX # <br /> 4901 Warehouse Way ( ) <br /> CITY STATE ZIP <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 /> 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 : ge� 9aj DATE : 11 / 1 /21 <br /> PROPERTY / BUSINESS OWNER ❑ OPERATOR / MANAGER OTHER AUTHORIZED AGENT 13 Contractor <br /> If APPLICANT is not the BILLING PARTY, /goof 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 /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the Same time It Is provided t0 me Or <br /> my representative . (� <br /> TYPE OF SERVICE REQUESTED : �j r j <br /> COMMENTS : a , _ <br /> � V <br /> S1 <br /> JO <br /> Q �? <br /> yEA T N OF g COU <br /> T Y <br /> TNj <br /> ACCEPTED BY : / EMPLOYEE # : DATE: f �J <br /> ASSIGNED TO : EMPLOYEE #: DATE: 1002 <br /> v ' <br /> Date Service Completed ( if already completed) : SERVICE CODE : AI <br /> I FO� 2q6 P I E230P <br /> Fee Amount: 4$9" voa vo Amount Paid [�S� 06 Payment Date <br /> Payment Type SU Invoice # Check # Recei ed By : <br /> EHD 48-02-025 SR FORM (Golden Rod) <br /> 07/17/08 <br />