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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />CONTRACTOR/ <br />FACILITY IC # <br />SERVICE REQUEST # <br />Fuel dispensing station <br />COMMENTS: <br />�1Q&nno 11�1/WW I °>I/vr v°. <br />RawvMm <br />$Ra.5m 1 "7Z5 <br />OWNER I OP OR <br />J' <br />REQUIESTOR <br />CHECK O BILLING ADDRESS13 <br />FACILITY NAME <br />i <br />George Kishida <br />DATE: ' <br />v <br />ASSIGNED TO: EMPLOYEE rn�%v j I EMPLOYEE #: <br />CHECX it BILLING ADDRESS <br />SITE ADDRESS 1728 <br />SERVICE COOS; <br />Ackerman Drive <br />PIE: 0 <br />Lodi � <br />95240 <br />Street Number <br />Djructliqn <br />E T• <br />Street Name <br />Cll <br />Zip Code <br />HOME or MAILING ADDRESS (if Different from Site Address) <br />HOME or MAILING ADDRESS <br />strlwl Num)wr <br />Street Ngme <br />CITY <br />i <br />STATE ZIP <br />PHONE #1 Exr. <br />APINI #I <br />CITY <br />LAND USE APPLICATION # <br />(91 G 1 368-060:1 14 <br />i <br />PHONE tiZ EXT. <br />65651 <br />BIDS DISTRICT <br />LOCATION CODE <br />acknowledge that all site and/or <br />project specific ENVIRONMI NTAL HEALTH <br />DEPARTMENT hourly charges <br />associated with this project 0 <br />I also certify that I have prepared this application and ;that the work to be performed will be done in accordance with all <br />SERVICE <br />REQIIESTOR <br />- <br />COMMENTS: <br />�1Q&nno 11�1/WW I °>I/vr v°. <br />RawvMm <br />l'1 <br />. C/ Y Y YY <br />J' <br />REQUIESTOR <br />i <br />2 tAL*v(n+et)avcc <br />DATE: ' <br />v <br />ASSIGNED TO: EMPLOYEE rn�%v j I EMPLOYEE #: <br />CHECX it BILLING ADDRESS <br />Date Service Completed (it already completed): <br />SERVICE COOS; <br />PIE: 0 <br />BUSINESS NAME <br />PHONE# <br />E T• <br />HZ Msunten�nre <br />payment <br />Date <br />916 1371,2360 <br />HOME or MAILING ADDRESS <br />Payment Type Invoice # Check # 3Q0. f� I <br />vUU <br />FAX# <br />Received By: <br />Pfd Box 933 <br />( ) <br />CITY <br />STATE <br />Zip <br />rA <br />65651 <br />BILLING ACKNOWLEDGEMENT I, the underslgned property or <br />business owner, operator or authorized agent of same <br />acknowledge that all site and/or <br />project specific ENVIRONMI NTAL HEALTH <br />DEPARTMENT hourly charges <br />associated with this project 0 <br />activity will be billed to me or my <br />business as identified on this form. <br />SAN JOAQUIN <br />COUNTY Ordinance Codes, StandarrJs, STATE and F'EDErAL la_wc <br />APPLICANT'S SIGNATURE: DATE: �i AIq }I�` <br />PROPERTY / BUSINESS OWNER ❑ OPERATOR i MANAGER ❑ OTHER AUTHORIZED AGENT ❑ C�I�, <br />If APPLICANT i5 not the BILLING PARTY. proof of authorization to sign is required Tert a ♦O <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable. I, the owner or operator of the property to a�fh�a <br />site address, hereby authorize the release of any and,all results, geotechnical data and/or environmentaUsite ass s5 14' 4214izo o 025 <br />t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It IS available and at the same time it i <br />my representative. <br />TYPE OF SERVICE REQUESTED: <br />LA S ( F <br />COMMENTS: <br />�1Q&nno 11�1/WW I °>I/vr v°. <br />RawvMm <br />l'1 <br />. C/ Y Y YY <br />n1� (, STP <br />AC:CEP FED 13Y: [ EMPLOYEE go <br />DATE: ' <br />v <br />ASSIGNED TO: EMPLOYEE rn�%v j I EMPLOYEE #: <br />DATE; <br />Date Service Completed (it already completed): <br />SERVICE COOS; <br />PIE: 0 <br />Fee Amount: 1 r s <br />Amount;paid r <br />payment <br />Date <br />Payment Type Invoice # Check # 3Q0. f� I <br />vUU <br />Received By: <br />EHD 45-02-025 <br />5R FORM (GDlden Rod) <br />07117106 <br />