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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # SERVICE REQUEST # <br /> RETAIL GAS STATION <br /> OWNER / OPERATOR <br /> MR . JIM RUBNITZ ( APPLICANT) CHECK If BILLING ADDRESS ❑ <br /> FACILITY NAME MOUNTAIN HOUSE CHEVRON <br /> SITE ADDRESS NEC OF INTERNATIONAL PARKWAY TRACY <br /> Street Number Drection & DAYLIGHT Rg Name city ]�Zln C <br /> ode <br /> HOME or MAILING ADDRESS (If Different from Site Address ) BLANCHARD DRIVE <br /> 17610 Street Number Street Nanle <br /> CITY MONTE SERENO STATE CA Zip 95030 <br /> PHONE #1 EXT. APN # PORTION OF LAND USE APPLICATION # <br /> ( 408 ) 813 -6416 209 -460 -35 <br /> PHONE #2 EXT• BOS DISTRICT LOCATION CODE <br /> CONTRACTOR i SERVICE REQUESTOR <br /> REQUESTOR MR . MUTHANA IBRAHIM ( MUTHANA@MIARCHITECT. COM ) CHECK if BILLING ADDRESS ❑ <br /> BUSINESS NAME PHONE # EXT• <br /> M I ARCHITECTS, INC . 925 2874174 1# <br /> HOME or MAILING ADDRESS 2221 OLYMPIC BLVD , , SUITE 100 FAX # <br /> ( 925 ) 943 - 1581 <br /> CITY WALNUT CREEK STATE CA ZIP 94595 <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 DEPARTIMENr 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 apptication 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 : ' :Z- <br /> DATE : '� T <br /> PROPERTY / BUSINI3SS OWNER ❑ OPERATOR / MANAGER ® OTHER AUT [ IORIZED AGENT ❑ <br /> 1J1f1PPLIC1hVT 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 die property located at the <br /> above site address, hereby authorize die 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 available ai ijj the same tine it is <br /> provided to me or my representative. e <br /> TYPE OF SERVICE REQUESTED : S` TL-L/ �/ <br /> vt <br /> CONIMENTS : J/ / <br /> NFq Ty OpP�FNr 'IV <br /> Rr�jFNr <br /> ACCEPTED BY : l f ���� EMPLOYEE # : DATE : 7 <br /> ASSIGNED TO : v �.- ✓/ C/`� EMPLOYEE #: DATE : � z 7 Z <br /> Date Service Completed (if already completed ) : SERVICE CODE : 0 3� P / E: <br /> 0 1 / <br /> Fee Amount : � � L10 <br /> &�v Amount Pai 3646, <br /> ob Payment Date <br /> Payment Type Invoice # Check # 12 'S eceed By : <br /> EHD 48-02-025 SR FORM (Golden Rod) <br /> REVISED 11 /17/2003 <br />