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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT JUL 13 Z016 <br /> SERVICE REQUESTrrl�' w3 , <br /> Type of Business or Property FACILITY ID# SERVICE <br /> Gas Station s F(}660 1 as S 067'5 2 <br /> OWNER/OPERATOR <br /> Quick Stop Markets Inc CHECK IfBILUNGADDRESS❑ <br /> FACILITY NAME <br /> Quick Stop f <br /> SITE ADDRESS 151✓G' Trac 95376 <br /> 1153 Lincoln aAfrip Y <br /> Street Number Direction I Street Name city Zip Code <br /> HOME or MAILING ADDRESS (if Different from Site Address) <br /> Enterprise Street <br /> 4567 Street Number Street Name <br /> CITY STATE Ca ZIP 95438 <br /> Fremont <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> ( 209 835-8284 D <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( 800) 972-0982 <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR <br /> Megan Mitchell CHECK If BILLING ADDRESS <br /> BUSINESS NAME Elite IV Contractors PHONE# EXT. <br /> (209)461-6337 <br /> HOME Or MAILING ADDRESS FAX# <br /> 2535 Wigwam Dr ( 2og 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 <br /> or activity will be billed to me or my business as identified on this form. <br /> s <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: 7 ga'9171k&4& DATE: 7/13/2016 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT LO 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 <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. p <br /> TYPE OF SERVICE REQUESTED: Replace Leak Detector / FCF Np <br /> COMMENTS: ` 1 <br /> 4S4'1,7' <br /> D4 <br /> H �4 8F <br /> - <br /> ACCEPTED BY: Q ,�/t EMPLOYEE#: DATE: -7 <br /> ASSIGNED TO: - � v1 EMPLOYEE DATE: <br /> Date Service Completed (if already completed): RVICE CODE: PIE: <br /> Fee Amount: Amount Pai 394.07 Payment Date <br /> Payment Type - Invoice# Ch k# D`I��S,S Rec ived By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />