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SAN JOAQUAOUNTY ENVIRONMENTAL IMPLUAkRTMENT <br /> SERVICE R]EQMRONMENTAL, <br /> Type of Business or Property Gas Station FACT mcQ^° "c:"" SERVICE REQUEST# <br /> 3w�_l C!W07/ '?�-'o <br /> OWNER/OPERATOR <br /> Thier Phain CHECK if BILLING ADDRESS <br /> FACILITY NAME California Stop <br /> SITE ADDRESS 2224 Manthey Rd Stockton 95206 <br /> 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 ) 406-1484 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR Kim White <br /> CHECK If BILLING ADDRESS <br /> ONE# EXT' <br /> BUSINESS NAME Elite IV Contractors PH209 461-6337 <br /> HOME or MAILING ADDRESS 2535 Wigwam Dr FAx# 461-6342 <br /> ( 209) <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 /> 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 /> /J 3/17/15 <br /> APPLICANT'S SIGNATURE: C442� _r� DAVE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT 12 Office Manager <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 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: EXPEDITE REVIEW-REPLACE FAILED 87 FILL BUCKET R yMENT <br /> COMMENTS: lvjEjD <br /> A4? 17 2015 <br /> S% QUAY <br /> Ham` f��TM� <br /> ACCEPTED BY: ( )(,(f.� EMPLOYEE#: DATE: <br /> ASSIGNED TO: ME-G _ EMPLOYEE#: DATE: <br /> Date Service Completed (if already complete SERVICE CODE: �i P I E: QjOg <br /> Fee Amount: s j�n° Amount Pai �$S (fib Payment Date 3 RIs <br /> Payment Type 56— Invoice# Ch # (f , A"'7/ /4. Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />