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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 A ,^Glfl II J „ o D 00( (OWN , <br /> OWNER / OPERATOR � V �C/ <br /> Aasim Enterprises CHECK If BILLING ADDRESS <br /> FACILITY NAME Chevron 460 Stockton <br /> SITE ADDRESS 10878 North Hwy 99 Stockton 95212 <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 ExT• APN # LAND USE APPLICATION # <br /> ( ) 707486-8894 <br /> PHONE #T 209-931 -6154 EXT, BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR John Baylis CHECK If BILLING ADDRESS © <br /> BUSINESS NAME IEC Services PHONE # ExT. <br /> 916-993 -6312 <br /> HOME or MAILING ADDRESS FAX # <br /> 4901 Warehouse Way ( ) <br /> CITY STATECA ZIP � � �12) ri <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 : 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 IOcaNwaydQ t the above <br /> site address , hereby authorize the release of any and all results , geotechnical data and/or environmental/site assessmation <br /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as Soon as It IS available and at the Same time it IS <br /> my representative . / <br /> TYPE OF SERVICE REQUESTED : j �y7���y ,J ./U <br /> N I <br /> COMMENTS : / kg el bt/L� � 0 mile lis �04Qtj ;21 <br /> r;0-� , h�ALTII0 PMENr�NT <br /> 4RTMFNt <br /> ACCEPTED BY : EMPLOYEE # : DATE : <br /> ASSIGNED TO : h ` EMPLOYEE # : DATE: ( <br /> Date Service Completed ( if already competed : SERVICE CODE : Y2 t P I E� � <br /> Fee Amount: 41112 � o Amount Pa ' L � � on Payment Date <br /> Payment Type Sti Invoice # � ` Check # 12G Receive By : <br /> EHD 48-02-025 SR FORM (Golden Rod) <br /> 07/ 17/08 <br />