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SAN JOAQ� COUNTY ENVIRONMENTAL HEA 1 DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> GAS STATION �A 5(,003(101121 <br /> OWN R/ OPERA <br /> - /D Q B _ <br /> yL� /l ({,Jit,, GG7TI CHECK if BILLING ADDRESS O <br /> FACILI N <br /> SITE ADDRESS <br /> Street Number Direction t�/[V� StreLet(Name Cit �7i—d <br /> HOME Or MA NG ADDRESS (If Different from Site Address) C 1' <br /> 1 <br /> Street Number �rlL Street Name me <br /> CITY <br /> ATE ZIP� ,� „t} <br /> PHONE#'I EXT. APN# LAND USE APPLICATION# �-�'`JC <br /> P ONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> WO) <br /> CONTRACTOR It SERVICE RE' QUESTOR <br /> REQUEST O j - <br /> �� CHECK if BILLING ADDRESS <br /> BUSINESS NAME ccs` PHONE# EXT. <br /> ELITE IV CONTRACTORS, INC. (209 ) 461 -6337 <br /> HOME or MAILING ADDRESS FAx# <br /> 2535 WIGWAM DRIVE (209 ) 461 -6342 <br /> CITY STOCKTON STATE CA ZIP 95205 <br /> BILLING ACICNOWL,EDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific ENVIRONMENTAL I-ILALTIi 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 th' application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codas,Stands d, STATE and FEDERAL law <br /> APPLICANT'S SIGNATURE: J /J <br /> DATE: / <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTIIFR AUTHORIZED AGENT <br /> /f APPLICANT is not the BILLING PARTY,proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASF, 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 HEAL'T'H DEPARTMENT as soon as it is available and at the same time it <br /> provided to me or my representative. mEN <br /> TYPE OF SERVICE REQUESTED: RECEIVED <br /> COMMENTS: <br /> Noy 12 2003 <br /> SAN JOAQUIN C"M <br /> STN pEpENTAL <br /> ART�T <br /> In At <br /> APPROVED BY: EMPLOYEE#: Wy DATE: It /2 1,93 <br /> ASSIGNED TO: <br /> EMPLOYEE#: <br /> J0 DATE: l ri- Q 2 <br /> Date Service Completed (if already completed): SERVICE CODE: �` P t E:, O <br /> Fee Amount: Amount Paid [Payment Date <br /> Payment Type Invoice# Check# —79D3 Received By: l� <br /> EHD 48-01-025 SERVICE REQUEST FORM <br /> REVISED 6-5-02 <br />