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SAN JOAQUir, COUNTY ENVIRONMENTAL HEALTH LEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID# SERVICE REQUEST# GAS STATION, SALE OF FOOD ITEMS & 1)1. BEVERAGES, AND CAR WASH FACILITY "1 OWNER/OPERATOR RALEY'S CHECK If BILLING ADDRESS FACILITY NAME RALEY'S FUEL STATION #356 SITE ADDRESS 4255 E MORADA LANE STOCKTON 95212 `—Street Number Direction Street Name Ci Zi Code HOME or MAILING ADDRESS (If Different from Site Address) 500 WEST CAPITOL AVENUE Street Number Street Name CITY WEST SACRAMENTO CA STATE 95605 ZIP PHONE#1 EXT. APN# LAND USE APPLICATION# ( 916) 373-3333 124-290-08 USE PERMIT #UP-123-03 PHONE#2 ExT• BOS DISTRICT LOCATION CODE ( ) CONTRACTOR/ SERVICE REQUESTOR REQUESTOR JESSICA BORLAND c/o PERMITS PLUS CHECK If BILLING ADDRESS❑ BUSINESS NAME PHONE# EXT. RALEY'S FUEL STATION #356 916 788-2065 HOME Or MAILING ADDRESS FAX# 1206 McKINLEY DRIVE (916) 788-2048 CITY ROSEVILLE CA STATE 95661 ZIP BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as identified on this form. 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 COUNTY Ordinance Codes,Standards,STATE and FEDERAL laws. APPLICANT'S SIGNATURE: DATE: IL>•%2• C70; PROPERTY/BUSINESS OWNER❑ OPERATOR/MA AGER 171OTHER AUTHORIZED AGENT El.E rVvt.�"S�uS If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required Title AUTHORIZATION TO RELEASE INFORMATION: When applicable, I,the owner or operator of the property located at the above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at Yn sa k. a it is provided to me or my representative. PA. . EN 1 TYPE OF SERVICE REQUESTED: COMMENTS: food plawi 1t�fa;J7a2n6,f,9tve l2F ycts ED.�. pC� 1 SW FNS G;