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SAN JOAQUIPOUNTY ENVIRONMENTAL HEALTH 9PARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />Michael Armour <br />SERVICE REQUEST # <br />Gas Station <br />0o <br />��� <br />c <br />OWNER / OPERATOR <br />707 437-6668 <br />HOME or MAILING ADDRESS <br />Convenience Retailers <br />FAX# <br />CHECK if BILLING ADDRESS❑ <br />FACILITY NAME <br />(707 ) 437-4357 <br />�naville <br />Facility 270 5446 <br />3 5 _ <br />Payment Date 3 Q <br />SITE ADDRESS <br />Invoice # <br />Country Club Blvd. <br />Check # 2 ` 3 5S <br />Stockton <br />95204 <br />1403 Street Number <br />Direction <br />Street Name <br />city <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />191 <br />Iron <br />Point Road <br />Street NumberStreet <br />Name <br />Cl <br />ZIP <br />Mom <br />CAE 95630 <br />PHONE #1 Em. <br />APN # <br />LAND USE APPLICATION # <br />(916) 417-5298 Michelle Castle <br />123-232-46 <br />PHONE #2 ExT• <br />BOS DISTRICT <br />LOCATION CODE <br />(916 ) 425-9772 <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />YMENT <br />Michael Armour <br />CHECK if BILLING ADDRESS <br />BUSINESS NAME <br />PHONE # EXT. <br />Armour Petroleum Service and Equipment Corporation <br />ASSIGNED TO: p_p <br />707 437-6668 <br />HOME or MAILING ADDRESS <br />DATE: <br />FAX# <br />PO Box 507 <br />SERVICE CODE: <br />(707 ) 437-4357 <br />�naville <br />SftTE 95�I 6-0507 <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,S TE and FED laws. f <br />APPLICANT'S SIGNATURE: DATE: ✓ <br />PROPERTY / BUSINESs OWNER ❑ OPERATOR MANAGER El OTHER AUTHORIZED AGENT I <br />IfAPPLiCANT is not the B/LLING ARTY. 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. <br />TYPE OF SERVICE REQUESTED: V <br />YMENT <br />COMMENTS: <br />R <br />MAR 0 4 2010 <br />SAN JOAQUIN COUNTY <br />ENVIROENT <br />HEALTH DEPARTMENT <br />ACCEPTED BY: <br />EMPLOYEE #: <br />DATE: <br />ASSIGNED TO: p_p <br />EMPLOYEE #: <br />DATE: <br />Date Service Completed (if already completed): <br />SERVICE CODE: <br />P 1 E: <br />Fee Amount: � <br />Amount Paid <br />3 5 _ <br />Payment Date 3 Q <br />Payment Type j,, — <br />Invoice # <br />Check # 2 ` 3 5S <br />I Received By: VN(G._ <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />