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R E G,E D <br /> SEP 3 0 2016 <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE RE UEHEALTH <br /> Type of Business or Property FAUV115 6EPART EN-flERV/IICE REQUEST# <br /> Gas Station lC(' '):� 4 <br /> OWNER/OPERATOR <br /> Joe Loa CHECK if BILLING ADDRESS <br /> FACILITY NAME Fremont Food Mart <br /> SITE ADDRESS 2185 Fremont St Stockton 95205 <br /> Street Number I 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 ) 937-0195 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REOUESTOR Megan Mitchell CHECK If BILLING ADDRESS® <br /> BUSINESS NAME Elite IV Contractors PHONE# ExT. <br /> 209 461-6337 <br /> HOME or MAILING ADDRESS 2535 Wigwam Dr FAx# <br /> ( 209 ) 461-6342 <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 ENVIRONMr.N'I'AL 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 /> 1 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: W'4&� DATE: 9/29/2016 <br /> PROPERTY/BUSINESS OWNER❑ OPER4TOR MANAGER ❑ OTHER AUTHORIZED AGENT 0 Office Assistant <br /> If APPLICANT 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 JOAQOIN COUNTY ENVIRONMENTAL HEAL'I H 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: Need to replace 87 Annular Sensor and Overfill Acknowledgment Switch , Koy) ,, <br /> REC r trE►�+Ts: <br /> ^Cp 02016 <br /> SAN JO pNIME TMHTM <br /> A <br /> E.N'4 L <br /> HEX— <br /> ACCEPTED BY: C ( EMPLOYEE#: DATE: <br /> ASSIGNED TO: `JZG re-e' EMPLOYEE M DATE: ��- <br /> Date Service Completed (if already completed): SERVICE CODE: PI E: � <br /> Fee Amount: >Z Amount Pal 112Sr; Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />