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FILE COPY <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />Truck Stop <br />FACILITY ID # <br />F � <br />��' <br />SERVICE REQUEST # <br />JAN 1 2017 <br />JOAQUINCOUW <br />N <br />NrH UEPA�T <br />BUSINESS NAME <br />#: <br />PHONE # EXT. <br />OWNER/ OPERATOR <br />ASSIGNED TO' <br />f <br />CHECK if BILLING ADDRESS <br />Love's Travel Stop <br />Date Service Completed (if already completed): <br />FAX # <br />765 E. Greg St <br />FACILITY NAME <br />( 775) 358-4411 <br />CITY Sparks <br />STATE NV ZIP 89431 <br />Love's Travel Stop <br />y.. <br />Check # f ��'—g o <br />Received By: <br />SITE ADDRESS 1553 <br />Colony Rd <br />Ripon <br />95366 <br />t <br />Street Number <br />Di ectlon <br />Street Name <br />citv <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />SAME <br />Street Number <br />Street Name <br />CITY <br />STATE <br />ZIP <br />PHONE #1 Exr. <br />( ) <br />WN # <br />LAND USE APPLICATION # <br />PHONE #2 ExT. <br />( ) <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />CHECK if BILLING ADDRESS <br />Keith Perks <br />JAN 1 2017 <br />JOAQUINCOUW <br />N <br />NrH UEPA�T <br />BUSINESS NAME <br />#: <br />PHONE # EXT. <br />L.A. Perks Petroleum Specialists <br />ASSIGNED TO' <br />f <br />775 358-4403 <br />HOME Or MAILING ADDRESS <br />Date Service Completed (if already completed): <br />FAX # <br />765 E. Greg St <br />P/ E: r% 2 0 <br />J <br />( 775) 358-4411 <br />CITY Sparks <br />STATE NV ZIP 89431 <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 ant,FEDERAL laws. <br />1, <br />APPLICANT'S SIGNATURE: ti : ' DATE: 1116/17 <br />PROPERTY/ BUSINESS OWNER ❑ OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT ® Director <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 provided t0 me Or N <br />my representative. mpa... <br />TYPE OF SERVICE REQUESTED: <br />COMMENTS: <br />JAN 1 2017 <br />JOAQUINCOUW <br />N <br />NrH UEPA�T <br />ACCEPTED BY: PmEMPLOYEE <br />V <br />#: <br />DATE: <br />ASSIGNED TO' <br />f <br />EMPLOYEE #: <br />DATE: <br />Date Service Completed (if already completed): <br />SERVICE CODE: IlI <br />P/ E: r% 2 0 <br />J <br />Fee Amount: <br />Amount P>i li j PaymentDate �-r ? <br />Payment Type <br />Invoice # <br />y.. <br />Check # f ��'—g o <br />Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />07/17/08 <br />