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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # SERVICE REQUEST # <br /> Gas StationP 00 �31�31� <br /> OWNER / OPERATOR <br /> CHECK If BILLING ADDRESS <br /> Anabi Oil <br /> FACILITY NAME <br /> Shell <br /> SITE ADDRESS 2375 W Grant Line Road Tracy 95377 <br /> Street Number Direction Street Name City Zip Code <br /> HOME or MAILING ADDRESS ( If Different from Site Address) 1450 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 /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESSID <br /> Scott Willett <br /> BUSINESS NAME PHONE # EXT. <br /> DiMaggio Maintenance Inc . 760 722 - 9002 <br /> HOME or MAILING ADDRESS FAX # <br /> 1040 Joshua Wa (760 ) 722 - 9009 <br /> CITY Vista STATE CA ZIP 92081 <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 : T;%Wg DATE : 01 / 15/2021 <br /> PROPERTY / BUSINESS OWNER ❑ OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT ® Operations Manager <br /> If APPLICANT Is not the BILLING PARTY, proof of authorization to sigh 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 : <br /> COMMENTS : <br /> ACCEPTED BY : EMPLOYEE # : DATE: <br /> ASSIGNED TO : EMPLOYEE # : DATE : <br /> Date Service Completed ( If already completed) : SERVICE CODE : PIE : <br /> Fee Amount: Amount Paid Payment Date <br /> Payment Type Invoice # Check # Received By : <br /> EHD 48-02-025 SR FORM (Golden Rod) <br /> 07/17/08 <br />