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SAN J01PUIN COUNTY ENVIRONMENTAL HEARri DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property _ FACILITY ID# SERVICE REQUEST# <br /> Gas Station 1-1,1-z)(�(;�3 �'}Z 0���'(,/U�5 <br /> OWNER/OPERATOR <br /> Anabi Oil CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> Shell <br /> SITE ADDRESS 2375W Grant Line Road Tracy 95377 <br /> Street Number Direction Street Name City Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 1040 N. Benson Avenue <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> Upland CA 91786 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (760) 722 - 9002 <br /> PHONE#2 EXT• BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> Scott Willett CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT' <br /> 760 722 - 9002 <br /> HOME or MAILING ADDRESS FAX# <br /> 2603 IndustrV Avenue (760) 722 - 9009 <br /> CITY Oceanside STATE CA ZIP 92054 <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 or <br /> activity will be billed to me or my business as identified on this form. <br /> 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: 08/11/2017 <br /> PROPERTY I BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ® Project Manager <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 above <br /> site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information <br /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It IS available and at the same time It Is provided t0 me or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: PAYPAfiAlr <br /> COMMENTS: I ECEIVE <br /> j1 D <br /> -�. 1 <br /> �Gc� � � ' UG 14 20 AUi� i i 2017 <br /> 17 <br /> '"J AO,,, <br /> "FALTM DE A"irb'FN, ENVIF'; ` `JAL I <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: �J EMPLOYEE#: IDATE:2 I I <br /> Date Service Completed (if already completed): SERVICE CODE: j Lf PIE: ,L <br /> Fee Amount: (,�.56 Amount Pal /���� Payment Date 8 l7 <br /> Payment Type C4 Invoice# Check# ived By: <br /> a o%may <br /> EHD 48-02-025 7---Ka SR FORM(Golden Rod) <br /> 07/17/08 <br />