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SAN JOAQUL F COUNTY ENVIRONMENTAL HEALTH DuPARTmi NT <br />SERVICE REQUEST <br />Typo of Buelness or Property <br />FACILITY ID # <br />SERVICE REQUEST # <br />C- Store <br />CHECK If BILLING ADORE33 <br />OWNER/ OPERATOR <br />44 7Y <br />CHECK If BILLINGAooaEss <br />701 E. Dr Martin Luther King Jr Blvd. <br />DoNee Pump Company <br />FACILITYNAME <br />537-9396 <br />HOMP- or MAILING ADDRESS <br />GSG Gas & Mart <br />FAX# <br />DATE: a /O • ! -7 <br />$READDRESS <br />701 <br />l=ast <br />Martin Luther King Jr Blvd.. <br />I <br />Stockton <br />CITY Ceres <br />boor Number <br />rton <br />. 44get Neirto <br />Paymont Type I/ <br />ck, <br />ZIP Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Race vod By: <br />uSkeet <br />Namq <br />CITY <br />STATE <br />LP <br />PHONE #1 ExT. <br />APN # <br />X173`%% <br />LAND USE APPLICATION ag <br />t 209) 993-1298 <br />j <br />PHotia#2 EXT. <br />( ) <br />808 DIBTRtCT LocAnoN Coos <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOari <br />/C` V <br />COMIIENT9; <br />Bonnie Garber <br />CHECK If BILLING ADORE33 <br />BUsINess NAME <br />44 7Y <br />PHONE # <br />Err, <br />DoNee Pump Company <br />209 <br />537-9396 <br />HOMP- or MAILING ADDRESS <br />FAX# <br />DATE: a /O • ! -7 <br />2826 Railroad Ave. <br />( 209) <br />537-9398 <br />CITY Ceres <br />STATE CA <br />ZIP 95307 <br />BILLING ACICNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br />acknowledge that all site and/or project specific ENVIRONIVENTAL HIRALTH DEPARTMENT hout)y 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 JOAQuTN <br />COUNTY Ordinance Codes, Standards, STATE and FED laws. <br />APPLICANT'S SIGNATURE: xrt1 llb DATE; 2/10/2017 <br />PROPERTY/ BUSINESS OWNER❑ OPERATOR /kfAN G R OTnP.RAim roRIZEDAGENTEZ Admin <br />IfAPPLTGANT Is n0/ the BILLING PARTY It oof of arrllrorizatloT! 10 Slg/r lS rerfl/lred T111e <br />AUTHORIZATION TO RELE H INFORWIATION: 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 envit�r entnUslto assessment <br />inforrantion to the SAN JOAQUIN COUNTY ENVIRONWNTAL HEALIH DEPARTMENT as soon as it IS availabl a—i> same time it Is <br />provided to me or my representative.F�_ FSA <br />TYPE OF SERVICE REQUESTED: <br />/C` V <br />COMIIENT9; <br />hRo UC <br />rh�FpgR <br />44 7Y <br />41T <br />ACCEPTED BY: <br />EMPLOYEE #: <br />DATE: a' f O - / -7 <br />AsSIGNEDTO: <br />EMPLOYEE#: <br />DATE: a /O • ! -7 <br />Date Service Completed (If already completed): <br />SERYICE CODE: )GJP <br />l E: ^1�$ <br />`t <br />Fee Amount: 417 ` <br />Amount Pa <br />. �tJ <br />Payment Date O <br />Paymont Type I/ <br />Invoice # <br />Check # <br />Race vod By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />