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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 - X <br /> 03 215 <br /> �(- <br /> OWNER / OPERATOR <br /> CHECK If BILLING ADDRESS <br /> Anabi Oil <br /> FACILITY NAME <br /> Shell <br /> SITE ADDRESS 3725 N Tracy Blvd Tracy 95377 <br /> Street Number Direction Street Name City Zip Code <br /> HOME or MAILING ADDRESS ( if Different from Site Address) 1450 N . Benson Avenue <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> Upland CA 91786 <br /> PHONE #1 EXT• APN # LAND USE APPLICATION # <br /> ( 760) 722 - 9002 <br /> PHONE #2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> Scott Willett CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE # EXT. <br /> DiMaggio Maintenance Inc . 760 277 - 2117 <br /> HOME or MAILING ADDRESS FAX # <br /> 1040 Joshua Wa (760 ) 722 - 9009 <br /> CITY Vista STATE CA zIP 92081 <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 IaWS . <br /> APPLICANT ' S SIGNATURE : DATE : 12/06/23 <br /> PROPERTY / BUSINESS OWNER ❑ OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT ® Operations Manager <br /> If APPLICANT is not the BILLING PARTY proof of authorization to sigh is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION : When applicable , 1 , 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 : mug ENT� <br /> COMMENTS : RECEIVED <br /> DEC 19 2023 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONNIENTAL <br /> HEALTH DCPARTNIENT <br /> ACCEPTED BY : 5 �� �ly EMPLOYEE # : DATE : r f <br /> ASSIGNED TO : J �ffir �r ,e f EMPLOYEE #: DATE : 15 /2- <br /> Date Service Completed ( if already completed ) : 6�--G a SERVICE CODE : %lf <br /> iF PIE : Z50c7 <br /> Fee Amount : (� Amount Paid d 1 / 2 Payment Date ! y <br /> Payment Type v �SR— Invoice # C er k # ?> C� ?J Received By : <br /> EHD 48-02-025 SR FORM (Golden Rod ) <br /> 07/ 17/08 <br />