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SAN JOAQUINOOUNTY ENVIRONMENTAL HEALTH AARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />B&T Service Station Contractors <br />SERVICE REQUEST # <br />CHP State Facility <br />BUSINESS NAME <br />B&T Service Station Contractors <br />oT325 -re, <br />10\00 77"?5e <br />OWNER / OPERATOR <br />HOME or MAILING ADDRESS <br />CHECK If BILLING ADDRESSO <br />California Highway Patrol <br />Payment Type C, L <br />630 South Frontage Road <br />FACILITY NAME <br />( 805) <br />929-8948 <br />California Highway Patrol #265 <br />STATE CA <br />ZIP 93444 <br />SITE ADDRESS 3330 <br />N. <br />Ad Art Road <br />I <br />Stockton <br />95215 <br />Street Number <br />Direction <br />Street Name <br />city <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Street Number <br />Street Name <br />CITY <br />STATE ZIP <br />PHONE #1 ExT. <br />APN # <br />�� 0 o <br />LAND USE APPLICATION # <br />( 916) 843-3806 <br />V <br />PHONE #2 ExT• <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />CHECK if BILLING ADDRESS <br />B&T Service Station Contractors <br />ASSIGNED TO: L O <br />EMPLOYEE #: 0 Q 3 I <br />BUSINESS NAME <br />B&T Service Station Contractors <br />Date Service Completed (if already completed): <br />PHONE # <br />805 <br />Exr. <br />929-8944 1002 <br />HOME or MAILING ADDRESS <br />Amount Paid LAS 6 ' C9 <br />FAX # <br />Payment Type C, L <br />630 South Frontage Road <br />Check # V7 (�- 6 <br />( 805) <br />929-8948 <br />CITY Nipomo <br />STATE CA <br />ZIP 93444 <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: g pa-4� DATE: 7/24/17 <br />PROPERTY / BUSINESS OWNER 13 OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT ® Project Coordinator <br />IfAPPLICANT 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 t0 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: u� <br />COMMENTS: <br />RECt►V Iv" <br />Jut 14 2917 <br />SAENTM ()EIPARTMEN <br />1 <br />HOWL <br />'C <br />4 2017 <br />ENVIRONMENTAL HEALTH <br />,-)FPARTMFNT <br />ACCEPTED BY: tvEMPLOYEE <br />#: -7, <br />DATE: .Z ILi-1 —7 <br />ASSIGNED TO: L O <br />EMPLOYEE #: 0 Q 3 I <br />DATE: I _ 'k/�� <br />Date Service Completed (if already completed): <br />SERVICE CODE:®?� <br />/Date <br />PIE. a3©LI <br />Fee Amount: Li DO <br />Amount Paid LAS 6 ' C9 <br />Payment — <br />Payment Type C, L <br />I Invoice # <br />Check # V7 (�- 6 <br />1 Received By: <br />EHD 48-02-025 <br />REVISED 11/17/2003 <br />'may <br />SR FORM (Golden Rod) <br />