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it G*t 1 v t:L <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MAR S 0 2016 <br /> SERVICE REQUESTENVIRONMNTAL <br /> Type of Business or Property FACILITY ID# SERVICE REQdEVPlr'­"^ +AIMKIT <br /> �A 3�31 ?N _5-Z)f <br /> OWNER/OPERATOR <br /> Gas Station CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> Waterloo Shell <br /> SITE ADDRESS I E Waterloo Rd Stockton 95205 <br /> 4315 Street Number Direction Street Name City Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> ( 209 ) 931-3674 C6-71 C)0-54 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR Carrie Miller CHECK if BILLING ADDRESS® <br /> BUSINESS NAME PHONE# EXT. <br /> Elite IV Contractors 209 461-6337 <br /> HOME or MAILING ADDRESS FAX# <br /> 2535 Wigwam Dr. (209 ) 461-6342 <br /> CITY Stockton STATE CA Zip 95205 <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 HEALTH DIiPAR"rMEN'Y hourly charges associated with this project <br /> or activity will be billed to me or my business as identified on this form. I <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,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: C,�24Wk&ADATE; 3/30/16 <br /> PROPERTY/BUSINESS OwNER❑ OPERATOR/MANAGER ❑ OTIIERAu'rnORIZEDAGE,NT1R Office Manager <br /> IfAPPLICANT is not the BlI LING PARTY,proof grauthorization 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 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 representative. <br /> TYPE OF SERVICE REQUESTED: S-4(91)Vent Line Vac Sensor <br /> COMMENTS: O <br /> Expedt y ti °z 11 <br /> ACCEPTED BY: EMPLOYEE M DATE:rcA <br /> ASSIGNED TO: r^ EMPLOYEE M DATE: W—� <br /> Date Service Completed (W already completed): SERVICE CODE: l� PIE: <br /> Fee Amount: Amount Pal 6_3�QD Payment Date1-195 1 �d <br /> Payment Type V f 5� Invoice# Ch # 7�U37 S Rece ed By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />