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AN JOAQUIN COUNTY FaNVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # SERVICE REQUEST # <br /> OWNER I OPERATOR <br /> Abdo Nashir CHECK IfBILLING ADDRESS <br /> FACILITY NAME Alpha Fast Gas <br /> SITE ADDRESS 2358 E Waterloo Rd Stockton 95205 <br /> Street Number Direction I 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 /> PH NE #t ,� - ExT• APN # LAND USE APPLICATION # <br /> ( <br /> PHONE #2 Exr. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> Megan Mitchell CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE # Er <br /> Elite IV Contractors 209 461 - 6337 <br /> HOME or MAILING ADDRESS FAx # <br /> 2535 Wigwam Dr ( 209 461 -6342 <br /> CITY Stockton STATE Ca ZIP <br /> 95 <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 : 23 <br /> DATE : C--' r. --> ) <br /> PROPERTY / BUSINESS OWNER ❑ OPERATOR / ANAGER ❑ OTHER AUTHORIZED AGENT ER nffiC:P. ASSistant <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 /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It IS available and at the same time It Is provided to me Or <br /> my representative . P <br /> TYPE OF SERVICE REQUESTED : <br /> COMMENTS : y) Q � ® <br /> 4n / ° <br /> SAN ✓ & 1g i <br /> ENVIAQUIIy <br /> �E9CT> p p�FNal Way <br /> ACCEPTED BY : � EMPLOYEE #: / 02/ DATE: /- y I <br /> DATE: <br /> ASSIGNED TO : EMPLOYEE # : fC��i/ 2 2� L� <br /> Date Service Completed ( if already completed ) : SERVICE/CODE : Iq PIE���� <br /> t <br /> Fee Amount : `G 0 r) Amount Paid i5� , 00 Payment Date ( Z7 / I <br /> Payment Type V 5o - Invoice # Check # /0 � 7G�G� Received By : <br /> EHD 48-02-025 SR FORM (Golden Rod) <br /> 07/17/08 <br /> DEPAMMEW <br />