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SAN JOAQUIN COUNTY ENVIRONMENTAL HE $ARTMENT <br /> SERVICE REQUEST 1 <br /> Type of Business or Property FACILITY^u4K SERVICE REQUEST# <br /> Gas Station 138 <br /> OWNER/OPERATOR <br /> Quick Stop Markets Inc CHECKifBILLINGADDRESS <br /> FACILITY NAME <br /> Quick Stop <br /> SITE ADDRESS Tracy95376 <br /> 1153 Lincoln Way <br /> Street Number I 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 Fremont STATE Ca ZIP 95438 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> ( 209 835-8284 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( 800) 972-0982 11 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> Megan Mitchell CHECK If BILLING ADDRESSEd <br /> # EXT. <br /> BUSINESS NAME Elite IV Contractors PHONE209 461-6337 <br /> HOME or MAILING ADDRESS FAX# <br /> 2535 Wigwam Dr ( ) 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 /> 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: 7/13/2016 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHERAUTHORIZEDAGENT[3 Office Assistant <br /> IfAPPLiCANT 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. <br /> TYPE OF SERVICE REQUESTED: Replace Leak Detector <br /> COMMENTS: <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: <br /> Fee Amount: Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />