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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTNIENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # SERVICE REQUEST # <br /> RETAIL GAS STATION Ir <br /> OWNER / OPERATOR <br /> MR , JIM RUBNITZ (APPLICANT) CHECK ifBILLINOADDREs50 <br /> FACIurtNAME MOUNTAIN HOUSE CHEVRON <br /> SITE ADDRESS ' ) Z I / , `� rN I�me A/�rl�4L J� L 5 177 <br /> 1 + /✓ (1 rl p k'Irt�.� �} � TRACY `I <br /> Street Number f rt n city Zia Code <br /> HOME or MAILING ADDRESS (If Different from Site Address ) BLANCHARD DRIVE <br /> 17610 Street Number <br /> I <br /> Clrr MONTE SERENO STATE CA ZIP 95030 <br /> i <br /> i <br /> PHONE #1 EXT 7APN # LAND USE APPLICATION # <br /> ( 408 ) 813 -6416 ZGs`� — y` Ap — l; V <br /> PHONE #2 Ext• BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> MR , MUTHANA IBRAHIM ( MUTHANA@MIARCHITECT. COM ) CHECKifBILu 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 ACKNOWLEDGEM_ NT: I, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific ENViRONMENTAI. HEALTEt 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 1 have prepared this application and that the work to be performed will be done in accordance with all SAN JO.AQUIN <br /> COUNTY Ordinance Codes, Standards�STATIi and FEDLa2AL laws . <br /> APPLICANT'S SIGNATURE :," ✓ 0 7 �7 • Z �� W <br /> PROPRRTY / BusrNF,ss OwNrlR ❑ OPER:ITOR / MANAGER ® Oil HER AurKoitIZCI) AGENT ❑ <br /> If APPLIC.'ANT is not the BILLING PIIR7Y proof of authorization to sign ds 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 the release of any and all results , geotechnical data and/or environmental/site assessment <br /> information to the SAN' JOAQUIN COUNTY ENVIRONMENT AL HEAI,e H DEPARTNIENT as soon as it is available and at the same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED : <br /> COMMENTS : <br /> JUL 2 6 2022 <br /> ENVIRONMENTAL HEAL H <br /> ACCEPTED BY: EMPLOYEE #: D <br /> ASSIGNED TO : EMPLOYEE # : DATE: <br /> Date Service Completed (if already completed ) : SERVICE CODE: P / E: <br /> Fee Amount: Amount Paid Payment Date <br /> Payment Type Invoice # Check # Received By: <br /> EHD 48 -02-025 SR FORM (Golden Rod ) <br /> REVISED 11117/2003 <br />