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JJL <br /> RUSH <br /> SAN JOAQUIN COUNTY ENVIRON EEAGH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> A0003010 5R)0-11q3V <br /> OWNER/OPERATOR CHECK If BILLING ADDRESS E] <br /> Johnny Riman <br /> FACILITY NAME US Gas <br /> SITE ADDRESS 749 E Dr. Marten Luther King Blvd Stockton 95206 <br /> Street Number Direction Street Na a City Zip Code <br /> HOME or MAILING ADDRESS (if Different from Site Address) <br /> Strret Numbef Street Name <br /> CITY STATE ZIP <br /> PHONE#1 P-aT• APN# LAND USE APPLICATION# <br /> (209 1 465-8979 <br /> PHONE92 E%r. BOS DISTRICT LOCATK/N CODE <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR Megan Mitchell CHECK If BILLING ADDRESS <br /> 13 <br /> BUSINESS NAME PHONE# En <br /> Elite IV Contractors 209461-6337 <br /> HOME or MAILING ADDRESS FAX# <br /> 2535 Wigwam Dr (2091 461-6342 <br /> CITY Stockton STATE Ca 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 and FEDERAL laws. _ <br /> APPLICANT'S SIGNATURE:�R40& Mltckea DATE: 7/17/2017 <br /> PROPERTY/BUSINESS OWNER 13 OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT. Office Assistant <br /> If APPLICANT is not rhe 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 t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it Is avaia and at the same time it is <br /> provided to me or my representative. /n� `A, <br /> TYPE OF SERVICE REQUESTED: WT V1 ETT----4z RFC NT S''' - -_- -� .a <br /> E <br /> p <br /> COMMENTS: /w , I ut JUL 18 2017 <br /> 7 <br /> ENVIRONMEN'iAL HEALTH <br /> DEPARTMEN <br /> ACCEPTED BY: y! W�V EMPLOYEE#: DATE:.1 7r O <br /> ASSIGNED TO: til EMPLOYEE DATE: I vV 1 <br /> Date Service Completed (If already completed): SERVICE CODE: I I E: <br /> Fee Amount: 10 Amount Pal 68 ,oD Payment Data 7 g <br /> Payment Type Viii invoice# Ch k tjB Re eivodBy: <br /> EHD 48-02-025 <br /> SR FORM(Golden Rod) <br /> REVISED 11!1712003 RUSH <br />