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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> Rinku Saini CHECK if BILLING ADDRESS <br /> FACILITY NAME <br /> Chevron <br /> SITEADDRESS 508 W Charter Way Stockton 95206 <br /> Street Number Direction Street Name City Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (209) 465-3440 46/t.;, <br /> PHONE#2 EXT. BOS DISTR CT/ LOCATION CODE <br /> ( ) �c) I <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> Megan Mitchell CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> Elite IV Contractors 20 461-6337 <br /> HOME or MAILING ADDRESS FAX# <br /> 2535 Wigwam Dr Stockton Ca 95205 ( 209461-6342 <br /> c'TY Stockton STATE Ca ZIP 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 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 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 laws. <br /> APPLICANT'S SIGNATURE: DATE: C <br /> PROPERTY/BUSINESS OWNER OPERATO /MANAGER ❑ OTHER AuTHORIZED AGENT P Offl('P. ASsiStant <br /> If APPLICANT is not the BILLLVG PARTY proof of authorization to Sign is required Title <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 DEPARTMF,NI as soon as it is available and at t04pT�tinge it is <br /> provided to me or my representative. - <br /> TYPE OF SERVICE REQUESTED: 1 /tb/ <br /> COMMENTS: JO <br /> H FNS/R QIJ/N C <br /> OIJ <br /> �IT'H nqR � Y <br /> �7 <br /> T <br /> ACCEPTED BY: LA Q t�c),- n ,, EMPLOYEE#: (? DATE: 3') <br /> ASSIGNED TO: +CNS ` EMPLOYEE#: C DATE; <br /> Date Service Completed (if already completed): SERVICE CODE: 601yP I E: rI7 0 <br /> Fee Amount: Amount Paid5� v� Payment Date <br /> Payment Type V, Invoice# Ch k# 7l/5037 Rei; ed By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />