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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 / Convenlance Store A0001q �7 se 0019 (0 t29 <br /> OWNER / OPERATOR ARCO MSCO Strauch Management LLC CHECK if BILLING ADDRESS ❑ <br /> FACILITY NAME <br /> ARCO # 7147 <br /> SITE ADDRESS 1206 East March Lane Stockton 95210 <br /> Street Number Direction Street Name City Zip Code <br /> HOME or MAILING ADDRESS ( If Different from Site Address) <br /> P . O . Box 6038 Street Number Street Name <br /> CITY STATE ZIP <br /> Artesia CA 90702 <br /> PHONE #1 EXT , APN # LAND USE APPLICATION # <br /> ( 847) 340 -3092 <br /> PHONE #2 EXT . BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR It SERVICE REQUESTOR <br /> REQUESTOR <br /> Merlin Bowen (Agent for Contractor) CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE # EXT , <br /> Gelller-Ryan, Inc, 925 551 . - 7555 <br /> HOME OrMAILING ADDRESS 6805 Sierra Court , Suite G �`' 5 551J888 <br /> CITY Dublin STATE CA zIP 94568 <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 : _ �' , ,��`1 � � �� DATE : w ���nz <br /> PROPERTY I BUSINESS OWNER ❑ OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT e Permit Te6h <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 J@fj�ided to me or <br /> my representative . / a— <br /> TYPE OF SERVICE REQUESTED : Dispenser-and—Turbine replacemertt �� ^I � 7 NO& � <br /> COMMENTS : � J <br /> 4 y <br /> 'Ja <br /> y� rti/�C CO ME <br /> ACCEPTED BY: � ' � � , EMPLOYEE M DATE : <br /> ASSIGNED TO : > { j� ) � ;(� C_ ' ' C 'i '. . ' EMPLOYEE # : DATE : W <br /> Date Service Completed ( if already completed) : _ -- SERVICE CODE : _ ` PIE : <br /> 2309 <br /> Fee Amount: 1 1 U Amount Paid 7L031 O � Payment Date I Z <br /> Payment Type � Invoice # Check # ;zo7 ZpY Receiv d By : 2 T71 <br /> EHD 48-02-025 SR FORM (Golden Rod ) <br /> 07/17/08 <br />