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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # nSERVICE REQUEST # <br /> Gas Station (7 �j'� Cj St4 n aggZ $3 <br /> OWNER / OPERATOR <br /> CHECK If BILLING ADDRESS <br /> Anabi Oil <br /> FACILITY NAME <br /> Shell <br /> SITE ADDRESS 3725 N Tracy Boulevard Tracy 95304 <br /> Street Number Direction Street Name City Zip Code <br /> HOME or MAILING ADDRESS ( If Different from Site Address) 1040 N . Benson Avenue <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> Upland CA 91786 <br /> PHONE #1 EXT, APN # LAND USE APPLICATION # <br /> ( 760) 722 - 9002 °� <br /> PHONE #2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) (20 57 0 <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR �/ <br /> CHECK If BILLING ADDRESS <br /> Scott Willett <br /> BUSINESS NAME PHONE # EXT. <br /> DiMaggio Maintenance Inc . 760 722 - 9002 <br /> HOME or MAILING ADDRESS FAX # <br /> 2603 Industry Avenue (760 ) 722 - 9009 <br /> CITY Oceanside STATE CA zIP 92054 <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 Or <br /> 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 /> APPLICANT' S SIGNATURE : DATE : 03/05/2020 <br /> PROPERTY / BUSINESS OWNER ❑ OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT ® Operations Manaqer <br /> If APPLICANT is not the BILLING PARTY, proof of authorization to SIQt1 is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION : When applicable , I , the owner or operator of the property located at the above <br /> site address , hereby authorize the release of any and all results , geotechnical data and/or environmental/site assessment information <br /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the Samek* , e it is provided to me or <br /> my representative . <br /> TYPE OF SERVICE REQUESTED : S r C'EF/ <br /> COMMENTS : <br /> 'J <br /> SAN /0 L 03 2020 <br /> AQ(ll <br /> NEg t TH Pq RUL T y <br /> ENT <br /> ACCEPTED BY: stvi I v d L/ EMPLOYEE # : DATE : <br /> ASSIGNED TO : \ t� \, O k LM EMPLOYEE # : DATE : <br /> Date Service Completed ( if already completed ) : SERVICE CODE : <br /> j h Piz / / 0 <br /> Fee Amount: /f v0 Amount Paid ��� 4 D � Payment Date ` <br /> Payment Type 1 ' Invoice # Check # I / bs Received By : <br /> EHD 48-02-025 SR FORM (Golden Rod) <br /> 07/17/08 <br />