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SAN•TOAQum CouNTY ENVIRONMENTAL HIS&A AIMATMENT <br /> SERVICE REQUEST "0,,,AMr <br /> Type of Business or Property FACILITY 04 1 IVSERVICE REQUEST# <br /> Gas Station Mini Mart <br /> OWNER l OPERATOR �I <br /> Ran'eet Singh OxEcKifBi6j!nGADORES <br /> SI_t <br /> FAaLm NAME Arco AM/PM <br /> SUE ADDRESS 1340 Colony Rd Ripon 95366 <br /> Street Numhmr inti lre•t N•rn• _ Cod* _ <br /> How or MAILING AcORESS (If Different from Site Address) <br /> Sure!Numb., _ Street hwo <br /> CrrY STATE zip <br /> PHONE V Ea, APN 8 LAND USE APPLICATION 0 <br /> (209) 599-7606 <br /> PHONE ire JIM. 803 DISTRICT LOCATION COOE <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR Megan Mitchell CHECX if eiLLING AWFMss 121 <br /> BuslNEssNANE Elite IV Contractors PHONE <br /> 461-6337 <br /> HOME or WAILING ADDRESS FAx 9 <br /> Elite IV Contractors <br /> ( 209) 461-6342 <br /> c'" Stockton STATE Ca Z'P 95205 <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DL-PARTMENT hourly charges associated with this project <br /> or activity will be billed to me or my business as identified on this form. <br /> I 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 /> CouwiY Ordinance Codes,Standards,STATE and FEDERAL laws. I <br /> APPLICANT'S SIGNATURE: DATE: 9I1412016 <br /> PROPER-1 V i BUSINM OWNERO OPLKATOR/MANAGER ❑ 0I`HER AtrrnoRizFD AGLh?IA Of ice Assistant <br /> 1f APPLiC 114'7'is not the 811.11NG PART).proof of authorization to sign is required Tirt e <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable,I,the owner or operator of the property located at the <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmentalfsite assessment <br /> information to the SAN JOAQUIN CouNTY ENVIRONMENTAL,HEALTH DEPARTMENT as soon as it is available and is <br /> provided to me or my representative. �zin <br /> r t Y 1 <br /> TYPEoF SERVICE REQUESTED: Repair Fill Sumps- Started on SR#70287 ! SR#73701 <br /> COMMEN S: <br /> SAN JOAQUIN COON <br /> ENVIROMENTAL <br /> HEALTH DEPARrAt1E <br /> ACCEPTED BY: t EMPLOYEE/: DATE: <br /> AsWONED TO: EMPLOYEE E: DATE.: <br /> Date Service Completed (if stramfy completed): SERVICE CODE: 1/ ' PIE: <br /> Fee Amount: -1 1 -7 1 <br /> Amount Paid 141-7 Payment Date Q if/5-//ta <br /> Payment Type ) 5a- Invoice• check• Reeelwd OV, . <br /> EHO 4"2-025 4� `$ 5R FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />