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nL,%J1.1 V IeL) <br /> SAN JOAQUIN ,.—JUNTY ENVIRONMENTAL HEALTH DLPARTMENT SEP 2 8 2015 <br /> SERVICE REQUEST �=NVIRONMENTAI- <br /> Type of Business or Property FACILITY ID# SERVIff AtWffT-4�T°" ,T <br /> Gas Station FAC)ob <br /> OWNER/OPERATOR <br /> Ruppi Padda CHECK if BILLING ADDRESS <br /> FACILITY NAME <br /> Waterloo Shell <br /> SITE ADDRESS 4315 E Waterloo Stockton 95215 <br /> Street Number DirectionStreet Name city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street NumberF Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> ( ) <br /> PHONE#2 EXT. BOS 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 /> 209 461-6337 <br /> HOME or MAILING ADDRESS FAX# <br /> 2535 Wigwam Dr. ( 209) 461-4342 <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 <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,STATE and FFDERAL laws. <br /> APPLICANT'S SIGNATURE: CDATE: 9/28/15 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT EX Office Manger <br /> IfAPPL/CANT is not the BILLING PARTY,proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: 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 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. A,q <br /> TYPE OF SERVICE REQUESTED: Dispenser#3/4 - UDC Repair <br /> COMMENTS: <br /> -10 ��1 <br /> O vEN <br /> ACCEPTED BY: EMPLOYEE#: DATE: 7 <br /> ASSIGNED TO: r►40 ,y EMPLOYEE#: DATE: `T/�Zs'/Ig- <br /> Date Service Completed (if already completed): SERVICE CODE: i UQ, PIE: <br /> Fee Amount: ` jC-CIO Amount Pai 3�0 �D Payment Date <br /> �/ zs/S <br /> Payment Type Invoice# Ch k# Received By <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />