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0 0 flEGEIVEC <br />SAN JOAQUiN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />NOV Q2, 2115 <br />ENVIRONMENTA I <br />dPTMI:A1T <br />Type of Business or Property <br />FACILITY <br />REQ <br />Gas Station <br />�—�� <br />=1DSERVICE <br />?DCjAo <br />(7WNl'sR 1 OPERATOR <br />Costco <br />ExT• <br />n <br />HF.4 <br />8h,M <br />209 <br />CHECK If ENLLING ADORESS0 <br />FACILITY NAME <br />FAX # <br />Costco <br />2535 Wigwam Dr. <br />SITE ADDRESS <br />461-6342 <br />CITY Stockton <br />STATE CA <br />ZIP 5205 <br />LATE: <br />2444 StreetNkumber <br />I p i <br />Daniels <br />—StEWNarno <br />Manteca,,, <br />9 -.,. <br />How or MAILING ADDRESS (If Different from Site Address) <br />3c7D 6 <br />Ttreat <br />1( <br />Payment Type S� <br />Street Numbe <br />Nam <br />CITY <br />STATE 75P <br />PHONE #'I Exr. <br />APN N <br />LAND USE APPLICATION # <br />( 209) 824-2860 <br />PHONE 92 ExT• <br />) <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />U S -T <br />Carrie MillerCHECK <br />if BILLING ADDRESS® <br />BUSINESS NAME <br />PHONE N <br />ExT• <br />Elite IV Contractors <br />HF.4 <br />8h,M <br />209 <br />461-6337 <br />HOME or MAILING ADDRESS <br />FAX # <br />MFti'r <br />2535 Wigwam Dr. <br />1 209) <br />461-6342 <br />CITY Stockton <br />STATE CA <br />ZIP 5205 <br />BILLING ACKNOWLEDGEMENT. 1, the undersigned property or business owner, operator or authorized agent of some, <br />acknowledge that all Site and/or project specific ENVIRONMENTAL HEALT[i DEPARTMENT hourly charges associated with this project <br />or activity will be billed to me or my business as identified on this form. <br />1 also certify that 1 have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQIJIN <br />COUNTY Ordinance Codes, Standards, STATE and FEDGRAL laws. <br />APPLICANT'S SIGNA'> VRE: <br />DATE: 10/30/15 <br />PROPERTY I BUSINESS OWNER© OPERATOR / MANAGER 0 0Tnr.R AU'rHoRIZED At:Enr a Office Manager <br />If APPLICANT is not the BILLING PARM proof Of authoriZation tosign is required Thle <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, 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 environmental/site assessment <br />information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMFNT as soon as it is available and at the sante time it is <br />provided to me or my representative. <br />Z%_ <br />TYPE OFSERVICE REQUESTED: 87 B Fill Sump <br />U S -T <br />COMMENT$: <br />of --so <br />SayvY � n <br />HF.4 <br />8h,M <br />7�'R ou <br />�FagR�.f��k <br />MFti'r <br />ACCEPTED BY: <br />EMPLOYEE #: <br />DATE: <br />ASSIGNED TO: V' <br />EMPLOYEE: <br />LATE: <br />Date Service Completed (if already completed): <br />SERVICE CODE: ejI <br />I PIE: Z,30 S <br />Fee Amount:5901L <br />Amount Pal -d"' <br />3c7D 6 <br />Payment Date <br />1( <br />Payment Type S� <br />Invoice # <br />C!eok# <br />Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 1111712003 <br />