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'ECEIVED <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT JAN 3 0 2019 <br /> SERVICE REQUEST <br /> Type of Business Or Property FACILITY ID# E VICE?tQQ ENT L <br /> (A NO? <br /> yy�jZ i,RTA FIST <br /> IAIJUJ � �15�t- , <br /> OWNER/OPERATOR <br /> Tony Singh CHECK If BILLING ADDRESS <br /> FACILITY NAME Chevron <br /> $READDRESS 25651 Hwy 99 Acampo 95220 <br /> stmet Number Direction Street Name City ZJD Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Nam <br /> CITY STATE zip <br /> PHONE#1 EXT' APN# LAND USE APPLICATION# <br /> (925 ) 783.6102 <br /> PHONE#2 EXr. BOB DISTRICT LOCATION CODE <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR Megan M CHECK If BILLING ADDRESS <br /> BUSINESS NAME HANE <br /> # <br /> Elite IV Contractors I igi 461-6337 <br /> HOME or MAILING ADDRESS 2535 Wigwam Dr FAX# <br /> (20961-0342 <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 or <br /> activity will be billed to me or my business as identified on this form. <br /> 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 /> APPLICANTa �N%C " <br /> S SIGNATURE: Ny DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ® Office ASsistant <br /> If APPLICANT IS not the BILLING PARTY,proof of authorization t0 sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, the owner Or operator of the property located at the above <br /> site address, hereby authorize the release of any and all results,geotechnical data and/or environmental/site assessment information <br /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It is available and at the same time It is provided t0 me or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: <br /> Pau- <br /> COMMENTS: <br /> RECEIVE® <br /> F $ 0 1 21319 <br /> ACCEPTED BY: L r EMPLOYEE#: mH p <br /> ASSIGNED TO: 'l EMPLOYEE#: DATE: • / 2V rZ <br /> Date Service Completed (If already completed): SERVICE CODE: PIE:306 <br /> Fee Amount: Amount Paid LkJ(a OO Payment Date Z l Ll <br /> 1' <br /> Payment Type v« Invoice# Check# Received By <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />