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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Eris <br /> OWNER/OPERATOR <br /> Angle CHECK If BILLING ADDRESS <br /> FACILITY NAME Angle Petroleum <br /> SITE ADDRESS 7700 Moreland Dr Stockton 95212 <br /> Street Number I Direction Street Name C ity 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 /> (510 ) 522-4822 <br /> PHONE#2 ExT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> Megan M CHECK If BILLING ADDRESSE] <br /> PHONE# EXT. <br /> BUSINESS NAME <br /> Elite IV Contractors 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: 1, 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 /> 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,STAKE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: / /�l DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT® 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, 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 COIINIY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at thtjartte time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: V � <br /> COMMENTS: Sq� ®s <br /> J <br /> O <br /> /Y V/R�N l COU <br /> ACCEPTED BY: t EMPLOYEE#: Ci /1�1 DATE: �1 3� f <br /> ASSIGNED TO: � r`�„/ EMPLOYEE M 1 4 �f DATE: CJ <br /> Date Service Completed (if already completed): SERVICE CODE:v PIE: <br /> Fee Amount: Amount Pai 7 .)(_o DD Payment Date S ID <br /> Payment Type Invoice# CheA# _ �3��d Rec ived By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />