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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> fA -r 5 N x-29 <br /> OWNER/OPERATOR <br /> Debbie CHECK If BILLING ADDRESS 1:1 <br /> FACILITY NAME Chevron <br /> SITEADDRESS 3775 N Tracy Boulevard Tracy 95304 <br /> Street Number I DirectionStreet Name City ZI Ccde <br /> HOME or MAILING ADDRESS (If Different from Site Address) `-. <br /> �� <br /> Street Number Street Name ? <br /> CITY STATE ZIP �cr <br /> Flp <br /> PHONENI E"T• APN# LANG USE APPLICATION# /.� <br /> ( 209 836-9427 Sa V J ? 2 R <br /> PHONE#2 ErT• BOS DISTRICT <br /> ( 1 LT NS.MBCO IY <br /> CONTRACTOR It SERVICE REQUESTOR T't'fFNT <br /> REQUESTOR <br /> Megan Mitchell CHECK HBILLING ADORES <br /> SCI <br /> BUSINESS NAME Elite IV Contractors PHONE# E>R <br /> (2091 461-6337 <br /> HOME or MAILING ADDRESS25,.35 Wigwam Dr FAz# <br /> 9 (209) 461-6342 <br /> CITY Stockton STATE Ca ZIP 95205 <br /> BILLING ACKNOWLEDGEMENT: 1, 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 /> /rc <br /> APPLICANT'S SIGNATURE: erg- /� asDATE: 211212018 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT IR Office Assistant <br /> 1fAPPL1CANT 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 to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is le and at the same Time itis <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: 07 <br /> I <br /> COMMENTS: <br /> RUSHENVIROEPAN MENT HE c'LTH <br /> ACCEPTED BY: VA(A li��n0 EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: �I <br /> Date Service Complete (If already completed): SERVICECODE: vt PIE: <br /> Fee Amount: Amount Paid (00O D Payment Date 1 (Lr <br /> Payment Type 5�_ invoice# ChD # 3/,Z/g� Received By: <br /> EHD 4ED 1111 SR�(Gaypl ppdj�o�� <br /> REVISED 1111712003 LE G <br />