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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # SR1E1V6 'Tj ST # <br /> OWNER / OPERATOR <br /> Debbie CHECK If BILLING ADDRESS <br /> FACILITY NAME Chevron <br /> SITE ADDRESS 3775 Tracy Blvd Tracy 95304 <br /> Street Number Direction Street Name c1tv Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Strout Name <br /> CITY STATE ZIP <br /> PHONE #1 ExT• APN # LAND USE APPLICATION # <br /> ( 209 ) 836-9422 <br /> PHONE #2 ExT• BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR Megan Mitchell CHECK if BILLING ADDRESS ® <br /> HONE # E%T. <br /> BUSINESS NAME Elite IV Contractors P209 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 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 /> 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 : DAT <br /> rE <br /> �: 5/1312020 <br /> 13u <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 , 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 /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it IS available and at the same time it is provided to me Or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED ; Vt S �� R '�'/ <br /> COh1MENTS: <br /> s ✓Ury 0 /SFO <br /> yFq"lv�R ?000 <br /> ` THCFpq FN��Np), <br /> ACCEPTED BY : /{ V EMPLOYEE M DATE: FNT <br /> ASSIGNED TO : 1 EMPLOYEE #: DATE : <br /> Date Service Completed ( if already completed : SERVICE CODE ; JqJ 11PIE : <br /> Fee Amount: ( j Amount PalLl 4::�CO Payment Date 0 <br /> Payment Type 54� Invoice # Check # l� / ; 3 S Redelved By : <br /> EHD 48-02-025 SR FORM (Golden Rod) <br /> 07/17/08 <br />