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SAN JOAQUI&OUNTY ENVIRONMENTAL HEALTOEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID.# SERVICE REQUEST# <br /> Gasoline Service Station 2 cl tf 2- <br /> OWNER/ <br /> OWNER/ OPERATOR Quikstop Markets, Inc El <br /> If BILLING ADDRESS <br /> FACILITY NAME Quikstop Site # 00152 <br /> SITE ADDRESS <br /> 1721 s 1721-1 Cherokee Lodi 95240 <br /> Street Number Direction Street Name City Zip Code <br /> HOME or MAILING ADDRESS(If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 510 445 2288EM' APN# LAND USE APPLICATION# <br /> PHONE#2 EM' BOS DISTRICT, LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR Roy Sof e <br /> CHECK If BILLING ADDRESS X/\ <br /> BUSINEss NAME Triangle Environmental, Inc PHONE# ExT. <br /> (818)840 7020 <br /> HOME or MAILING ADDRESS 2525 W. Burbank Blvd FAx# <br /> (818) 840 6959 <br /> CITY Burbank STATE CA ZIP 91505 <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 <br /> project 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 that the work to be performed will be done in accordance with all SAN <br /> JOAQUIN COUNTY Ordinance Codes,Standard , E and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: 8/25/2004 <br /> PROPERTY/BUSINESS OWNER ❑ OPERATO LaNAGER ❑ OTHER AUTHORIZED AGENT X <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 <br /> the 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 andpgyto come it <br /> is provided to me or my representative. RECEIVED <br /> TYPE OF SERVICE REQUESTED: Etc, 20M <br /> COMMENTS: <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARWEN <br /> APPROVED BY: 0L-E LICE C v'-A EMPLOYEE#: 3 2,J DATE: 3 0 <br /> ASSIGNED TO: 1-4--� EMPLOYEE#: 3-5-PO DATE': cP �{'ZC <br /> Date Service Completed (if already completed): SERVICE CODE: f`j P/ E:' 3. OP <br /> Fee Amount-42"'i-e O 1 Amount Paid 1$;119.Q D Payment Date 3 Of O <br /> Payment Invoice # Check# (oa-� Received By: ,,7 f <br /> Type <br /> EHD 48-01-025 SERVICE REQUEST FORM REVISED 6-5-02 <br />