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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# <br /> SERVICE RE UEST# <br /> Gas Station �� 9 L <br /> OWNER/OPERATOR <br /> Jivtesh Gill CHECK N BILLING ADDRESS <br /> FACILITY NAME Arch Arco Am Pm <br /> SITE ADDRESS S HWY 99 <br /> 4855 st"t wombat Stockton 95215 <br /> HOME Dr MAILING ADDRESS (If Different from Site Address) <br /> Stratl Numbar o <br /> CITY <br /> STATE zip <br /> PHONE#1 Err. APN# LAND USE APPLICATIONS <br /> (209 ) 948-2438 17926051 <br /> PHONE#Z En. SOS DISTRICT LOCATION CODE <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR <br /> Carrie Miller CHECK IfMUINGADDRESSP <br /> BUSINESS NAME PRONE# EXT. <br /> Elite IV Contrcators 209 461-6337 <br /> HOME or MAILING ADDRESS FAX# <br /> 2535 Wigwam Dr. ( 209) 461-6342 <br /> Cm 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,HEAL.11i 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: CClitiu, W4&4, DATE; 2/11/16 <br /> PROPERTY/BOSINESSONVNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZEDAGENTZ Office Manager <br /> 1(APPt1CANT isnot the BILLING PARTY Proof of authorization fo sign is required Tate <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 environntental/site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPAR'T'MENT as soon as it is available and at the sante time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: Addressing : CCR 2630(d)&CCR 2636(F) t -- <br /> ED rl <br /> S 11 20t6 FEB, 112016 <br /> AN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> EDEPA TMENVIRONMENTAL <br /> E <br /> ACCEPTED BY:C p EMPLOYEE#: DATE. <br /> ASSIGNED TO:, e.r-c EMPLOYEEM DATE: <br /> Date Service Completed (If already completed): 2/10/16 SERVICE CODE: PIE: 2 1 SS <br /> Fee Amo - - Amount P �S.D Payment Date <br /> Payment Type — Invoice# Ch # a �S Recelved By <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />