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1 <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# L SERVICE REQUEST# <br /> C- Store ��'�66 ,��1 Q� / (-7 7 <br /> OWNER I OPERATOR <br /> 701 E. Or Marlin Luther King Jr Blvd. CHECKIfOILUNGAoomss❑ <br /> FACILITY NAME <br /> GSG Gas&Mart <br /> SiTEADORESS East Martin Luther King Jr Blvd.. <br /> 701 StocktonStreel Number ![on Name Vo Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number <br /> CITY STATE zip <br /> PHONE#1 EX1. APN# _ LAND USE APPLICATION 9 <br /> " ( 209) 993-1298 �47.�43j 1 <br /> PHONE#2 Err. SOS DISTRICT LOCAnoNCODE <br /> ( ) <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR <br /> Bonnie Garber CHECK If BILLING ADDRESS� <br /> BUSINESS NAME PHONE# Exi• <br /> Donlee Pump Company 209 537-9396 <br /> HOME or MAILING ADDRESS FAX# <br /> 2825 Railroad Ave. ( 209 ) 537-9398 <br /> CITY Ceres STATE CA ZIP 95307 <br /> BILLING ACI(NOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARIMENT 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 JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STAN and FED laws. <br /> 7 ` <br /> APPLICANT'S SIGNATURE: DATE: 2/10/2017 <br /> PROPERTY/BUSINESS OWNE+R❑ <br /> OPERATOR/ R OTHP•RAUTimnrzEDAGENT� Admin <br /> If APPLICANT is not the BILLING PARTY,p oof of an th orization to sign is regnired Title <br /> AUTHORIZATION TO RELEASE INFORNIATION: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 envir entat/site assessment <br /> information to the SAN JOAQUIN COUNTY ENvIRONMF.NTAL HEALTH DEPARTMENI as soon as it is availabl@same time it is <br /> provided to me or my representative. R F <br /> TYPE OF SERVICE REQUESTED: LA <br /> COMMENTS: D <br /> H �MJ�iR <br /> EqQiy 20�� <br /> l <br /> "Yo ,ogRT TgCh� <br /> MFNT <br /> ACCEPTED BY: EMPLOYEE#: DATE: o?. ' <br /> ASSIGNED TO: EMPLOYEE#: DATE: /O /- <br /> Date Service Completed (if already completed): SERVICE CODE: Ic' PIE: <br /> ate$ <br /> Fee Amount: Amount Pal 1Z. Payment Date �O <br /> Payment Type V� Invoice# Check# 4� Tv Rece ved By; <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/1712003 <br />