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RECEIVED <br /> DEC 16 2015 <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST ENVIRONMENTAL <br /> Type of Business or Property Q HEALTH DEPARTMENT <br /> FACILITY ID$ SERVICE REQUEST$ <br /> Gas Station i� M I� vf�f�7'3gg� <br /> OWNER/OPERATOR T <br /> Tony Haggard CHECK if BILLING ADDRESS <br /> FACILITY NAME <br /> Costco #658 <br /> 51T3ADUDRESS yY Grantline Rd Trac <br /> Strast Number DI tion Y 95376 <br /> et Neme <br /> HOME or MAILING ADDRESS (If Different from Site Address) ci Zip Cotle <br /> CITY Street Number Street Neme <br /> STATE LP <br /> PHONE 111 En. APN0 LAND USE APPLICATION IF <br /> ( 209) 834-1247 <br /> PHONE 82 ExT. BOS DISTRICT <br /> ( ) LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR Carrie Miller <br /> CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE Ex*. <br /> Elite IV Contractors 2091 461-6337 <br /> HOME or MAILING ADDRESS FAX R <br /> 2535 Wigwam Dr ( 209) 461-6342 <br /> Crtv 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.; r project specific ENVIRONMEN'CAI,HEALTH DEPARTMeN r 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 JOARuIN <br /> COUNTY Ordinance Codes,Srandardr,STATE a-nd FEDERAL laws. <br /> C444.44-APPLICANT'S SIGNATURE: ---- ? W,&4, DATE: 12/16/15 <br /> PROPERTY J BUSINCRN OWNER❑ OPERATOR/NIANAGER ❑ OTHERAUIHORIZEDAGENT IR. Office Manager <br /> /f APPLICANT is 00t the Bil-LING PARTY,proof of authorlZappn 10,Sign Is regUired Tiue <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 ENVIRONMEN PAL HEALTH DEPARTMENT as soon as It is available and at the same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: Replacment Of#5/6(91)Product Shear Valve 05T - yM <br /> COMMENTS: <br /> FILE COPY yT�N04 x ' 20/5 <br /> o Cot/ <br /> ACCEPTED BY: DAh� <ryO P j�F <br /> p EMPLOYEE III <br /> ASSIGNED TO: IL K12' G EMPLOYEE ��; ( 1 'C•7 ••r <br /> Date Service Completed (if already completedl: SERVICE CODE: _ ,I FIE; 1 <br /> Fee Amount: �'1L.cu Amount Pal 3 [b•OD Paym.nl D.a / /] <br /> Payment TYPE Invoke$ C $ <br /> 714/7/ BY <br /> EHD 48-02-025 <br /> REVISED 11/17/2003 SR FORM(Golden Rod) <br />