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SAN JOAOUIN COI.1N T Y ENVIRONMENTAL HEALTH DEPARTMENT <br /> oERV0GE REQUEST <br /> Type of Business or Property FACILITY ID # SERVICE REQUEST # <br /> OWNER / OPERATOR <br /> Annie Sandhu CHECK IfBILLING ADDRESS <br /> FACILITY NAME CA Gasoline Inc <br /> SITE ADDRESS 2115 W Yosemite Ave Manteca 95337 <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 /> PHONE # 1 EXT, APN # C, LAND USE APPLICATION # <br /> ( 925) 785 -2000 � <br /> PHONE #2 EXT BOS DISTWT LOCATION CODE <br /> ( ) 3 0 <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> Megan Mitchell CHECK If BILLING ADDRESS <br /> BUSINESsNAME PHONE # EXT, <br /> Elite IV Contractors <br /> HOME or MAILING ADDRESS 2535 Wigwam Dr FAx # <br /> (209) 461 - 6342 <br /> CITY Stockton STATE Ca ZIP 95205 <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 /> 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 . f <br /> APPLICANT' S SIGNATURE : 7&4¢ a yL 7ee& DATE : <br /> PROPERTY / BUSINESS OWNER ❑ OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT Office 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 /> 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 . PA wvm <br /> TYPE OF SERVICE REQUESTED ; S I %�✓/ ' v17 t <br /> COMMENTS : <br /> DEC ® 6 2019 <br /> JOA1 0VV RONIN C®UNN <br /> n FALTH D PAR MEN <br /> ACCEPTED BY: ` ' f V EMPLOYEE #: DATE: � 2 LJ/1 el <br /> ASSIGNED TO : S , C V U l d'e /f EMPLOYEE #: DATE: <br /> Date Service Completed ( if already completed) : - SERVICE CODE : P I E : L• '�0 03r <br /> � <br /> Fee Amount: �}' 1 Amount Paid S� /J � Payment Date / il_� <br /> �-XoRt <br /> Payment Type Invoice # Check # GDZ12313 / Recel ed By: <br /> EHD 48 -02-025 SR FORM (Golden Rod) <br /> 07/17/08 <br />