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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Gas Station ��U ��� �kC,6 �L/(J� <br /> OWNER I OPERATOR <br /> Que CHECK If BILLING ADDRESSC� <br /> FACILITY NAME <br /> Flag City Chevron <br /> SITE ADDRESS 6421 Capitol Ave. Lodi 95242 <br /> Street Number Direction t Zip Cod* <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Str*et Number Stmot Name <br /> CITY STATE Zip <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> ( 209) 481-8180 Z.It <br /> PHONE#2 ExT• SOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> Carrie Miller CHECK If BILLING ADDRESS <br /> BUSINESS NAME Elite IV Contractors PHONE# EXT. <br /> HOME or MAILING ADDRESS FAX# <br /> 6421 Capitol Ave ( ) <br /> CITY Lodi STATE CA ZIP 95242 <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific ENVIRONMENTAL.HE;.AI.TH DEPARTMEmr 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 l have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQIIIN <br /> COUNTY Ordinance Codes,Standards,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: (�+ZtAZ�, NWA4. DATE: 1/28/16 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER 13 OTHER AUTHORIZED AGENT[* Office Manager <br /> If APPLICANT is not the BIL LINO PAR71%proof of authorization to sign is required Title <br /> AUTHORIZATION TOO 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 environntental/site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my <br /> representative. <br /> TYPE OF SWe41 <br /> ESTED: Replaced LD on 87 North Tank <br /> COMMENTS:Or-SW JAN 2 8 2016 <br /> 1 <br /> yp+�-Ro* ,es, ENVIRONMENTAL <br /> H&:,'rkHEALTH DEPARTME T <br /> ACCEPTED BY: � EMPLOYEE M DATE: <br /> ASSIGNED TO: EMPLOYEE M DATE: <br /> Date Service Completed (if already completed): 1/27/16 SERVICE CODE: 1 P 1 E:20 <br /> Fee Amount: Amount Pa' 70.66 Payment Date 2- <br /> Payment Type �� Invoice# Ch # Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />