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SAN JOAQU*OUNTY ENVIRONMENTAL HEALTHOLIARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Gas Station, Sale of Food Items & ? (Q 523 <br /> Beverages, and Carwash Cj �j Z, <br /> OWNER i OPERATOR <br /> Mike Gates C/O Raley I s CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> Oal <br /> SITE ADDRESS <br /> 4255 Street Number D coon Morada Lan(%.t eet Name Stockt <br /> 9r code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> WSooest Capitol Ave <br /> Street Number Street Name <br /> CITY STATE zip <br /> W. Sacramento CA 95605 <br /> PHONE#1 Ex. APN# LAND USE APPLICATION# <br /> (9161 373-3333 124-290-08 Use Permit #123-03 <br /> PHONE#2 Ext. eOS DISTRICT <br /> ( 1 LOCATION CODE <br /> " [ jt <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR <br /> Michael Carruth C/o Fillner Construction INC. CHECXHBILLING ADDRESS <br /> BUSINESS NAME PHONE# Ex. <br /> HOME Or MAILING ADDRESS FAX# <br /> 4470 Yankee Hill Rd 200 ( 1 <br /> CITU STATE zip <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 /> I also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUHN <br /> COUNTY Ordinance Codes,Standards,SG�� <br /> APPLICANT'S SIGNATURE: DATE: 4/24/07 4/24/07 <br /> PROPERTY/BUSINESS OWNER[] ERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT L`T k��j(ft�( <br /> IfAPPL/CANT is not the B/LL7NC 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 <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 aA the same time it is <br /> provided to me or my representative. F-'AYME <br /> NT <br /> TYPE OF SERVICE REQUESTED: u s - C.O�� �_�TTO „J ED <br /> COMMENTS: <br /> PR 2 4 2007 <br /> SAN JOAQUIN CO <br /> ENVIRONME O UN <br /> HEAULTH DEPARTMENT <br /> ACCEPTED BY: 0 Lt ver J'?4 <br /> EMPLOYEEM O Z/ DATE: � Zc00-7 <br /> ASSIGNED TO: N� EMPLOYEE M O.7S'J� DATE: of Zqf 07 <br /> Data Service Completed (if already completed): SERVICE CODE: Q t I PIE: 2 ? <br /> Fee Amount: q Amount Paid S, W Payment Date L� 2' f6/7 <br /> Payment Type ✓ Invoice# Check# Received By: <br /> Kts- <br /> EHD (125 SR FORM(Golden Rad) <br /> REVISEDSED 11/17/2003 <br />