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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Job No. 17866 <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Retail Gas Station } <br /> i r'7 ^ —•� � �Z <br /> OWNER/OPERATOR <br /> Grin Investments. Inc. <br /> CHECK if BILLING ADDRESS <br /> FACILITY NAME <br /> ARCO am/p <br /> SITE ADDRESS 6009 N. EI Dorado Street �Stoclkton F95207 <br /> Street Number Direction Street Name Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 62 <br /> N. Sierra Madre St. <br /> Street Number Street Name <br /> CITY STATE Zip <br /> Mountain House CA 95993 <br /> PHONE#1 ExT. APN# <br /> LAND USE APPLICATION# <br /> ( 408 ) 666-7359 081-260-64 P16-0342 <br /> PHONE#1 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> Alexia Dorsch CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> B a i i e ? <br /> 6,56-7426 <br /> HOME or MAILING ADDRESS Fax# <br /> 18215 72nd Avenue S. ( ) <br /> 251-8782 <br /> CITY Kent STATE WA Zip 98032 <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_ HEAL'T'H 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:��, DATE: 20{ —(7 <br /> PROPERTY/BUSINESS OWNER 20 OPERATOR/MANAGER ❑ OTHER A UTHORIZED AGENT❑ <br /> (APPLICANT is not the BILLING PART}' proof•of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1,the owner or operator o'-'tfhe Propevty larwd1,,at thy,. . _. <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or etel <br /> flnIment 11sitef%ssessinent <br /> infonnation to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is availrtld aT fftetisame time itis:- _, <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: u (� PAYM Air10, / !f, <br /> COMMENTS: <br /> AUG 0 a DEF' RT1"AEN_SANJOA . <br /> ENV/RQUI N COU <br /> H NMngpi�ENTAL <br /> ACCEPTED BY: 1 rl EMPLOYEE#: N� DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: C3 <br /> A ' <br /> _ ✓ �'-" <br /> Date Service Completed (if a r ady completed): SERVICE CODE: <br /> Fee Amount: /,,7—/47. no Amount Paid 0?_/4p Payment Date <br /> Payment Type -t Invoice# Check# ff l � ! ( (2 ` Received By: <br /> VISA—'/ ISA— y I�St� � lot'E — <br /> REVISED 11/17/2003 SR FORM(Golden Rod) <br /> T f) c� <br />