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F r SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property . FACILITY ID # SERVICE REQUEST # Retail Food Market PHONE# 425 A-6 �2Yy 54M-79651 OWNER / OPERATOR E] Adelfos Partners, contact Richard Sarris CHECK If BILLING ADDRESS FACILITY NAME ARCO AM/PM Cherokee and Newton SITE ADDRESS 3443 I Cherokee Road I Stockton 95205 Street Number Direction Street Name Cit Zip Code HOME or MAILING ADDRESS (If Different from Site Address) 13899 De Vries Road Street Number Street Name CITY Lodi STATE CA ZIP 95242 PHONE #1 EXT' IN # 7J i� lJ LAND USE APPLICATION # ( 209 ) 986-3085 132-060-01X, Invoice # P A-1700019 PHONE #2 EXT• Received By: BOS DISTRICT �-- LOCAA'nON CODE 01 ( ) V L CONTRACTOR / SERVICE REQUESTOR REQUESTOR Leslie Burnside . CHECK If BILLING ADDRESS El BUSINESS NAME Barghausen Consulting Engineers, Inc. PHONE# 425 EXT. 656-7426 HOME or MAILING ADDRESS 18215 72nd Avenue S. iRo Ui' 9CTy0Fp4TN)}- FAX# ( 425) 251-8782 CITY Kent STATE WA ZIP 98032 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 fort -ft 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: 4/26/18 PROPERTY/ BUSINESS OWNER❑ OPERATOR /MANAGER ❑ OTHER AUTHORIZED AGENT ® Project Manager If APPLICANT is not the BILLING PARTY, poo fo fauthorizat[on t0 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 th e time it is provided to me or my representative. �A��. TYPE OF SERVICE REQUESTED:cn� an . COMMENTS: Y Z, 118 iRo Ui' 9CTy0Fp4TN)}- MFNT ACCEPTED BY: EMPLOYEE M DATE: .1 7 ASSIGNED TO: - EMPLOYEE #: DATE: ±27 _ ru V Date Service Completed (if already completed)-.) SERVICE CODE: G 2� P / E: Fee Fee Amount: S Amount P 7J i� lJ Payment Date 4,/ Payment Type Invoice # _ Check # /lS Received By: EHD 48-02-025 REVISED 11 /17/2003 SR FORM (Golden Rod)