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0 0 <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />SERVICE REQUEST # <br />Gas Station <br />Ff�oDb2"J� <br />-'; wi�r� <br />OWNER / OPERATOR <br />Ernest Gianneochini <br />❑ <br />PHONE# <br />CHECK H Baurvc aoDREss <br />FACILITY NAME Ernies General Store <br />SITEADDRESS 4407 <br />E <br />Waterloo Rd <br />ACCEPTED BY: <br />Stockton <br />95215 <br />Stme[Number <br />n <br />( 209 ) <br />Streel Name <br />City <br />Zi <br />HOME Or MAILING ADDRESS (if Different from Site Address) <br />SERMICE CODE: 9 <br />I E: 3a <br />Street NUmi)e! <br />Sheet Name <br />CITY <br />STATE ZIP <br />PHONE#1 EXT. <br />( P09 1 931-2850 <br />APN# <br />LAND USE APPLICATION If <br />PHONE #2 EXT. <br />1 1 <br />SOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR I SERVICE REQUESTOR <br />REOUESTbR Megan Mitchell <br />9 <br />CHECK if El <br />COMMENTS: <br />BILLING ADDRESS <br />BUSINESS NAME Elite IV Contractors <br />PHONE# <br />Exi. <br />209 1 <br />461-6337 <br />HOME Or MAILING ADDRESS <br />ACCEPTED BY: <br />FAX # <br />EMPLOYEE M <br />2535 Wigwam Dr <br />ASSIONEDTO: <br />( 209 ) <br />461-6342 <br />CITY Stockton <br />STATE Ca <br />Zip 95205 <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 <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 <br />TTA/,ATTE-and FEDERAL law's. p� <br />APPLICANT'S SIGNATURE: eY2f L W'e4Z:IG¢G�. DATE: <br />PROPERTY/BUSINESS OWNER❑ OPERATOR/ MANAGER OTHER AUTHORIZED AGENT OfflceAssistant <br />IfAPPL1CANT is nol the BILLING 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 DEPARTMENT as soon as it is available and at the same time it is <br />provided to me or my representative, <br />A_ <br />TYPE OF SERVICE REQUESTED: tA S <br />4C,p, <br />COMMENTS: <br />6?41� <br />DUN <br />H'u �MF'Vl '1i• <br />ACCEPTED BY: <br />EMPLOYEE M <br />DATE, 2 <br />ASSIONEDTO: <br />EMPLOYEE #: <br />DATE: qv <br />Date Service Completed (If already Completed): <br />SERMICE CODE: 9 <br />I E: 3a <br />Fee Anlouni�jj �,-� s Amount Pal <br />625-,5 Payment Date <br />Payment Type V 15� Involee # <br />C ck# 6! �a / <br />Received By: <br />EHD 48-02-025 / <br />REVISED 11/17/2003 SR FORM (Golden Rod) <br />