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i <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> NEW CONVENIENCE STORE <br /> OWNER/OPERATOR <br /> RAVINDER SINGH CHECK if BILLING ADDRESS❑ <br /> FACILITY NAME WEST LN. CHEVRON <br /> SITE ADDRESS 4747 WEST LN. STOCKTON 95210 <br /> Street Number Direction Street Name Ci Zip Code <br /> HOME or MAILING ADDRESS (if Different from Site Address) <br /> Street Number Street Name <br /> CITY STOCKTON STATE CA ZIP <br /> 95210 <br /> PHONE#1 ExT. APN# LAND USE APPLICATION# <br /> (209) 992-1735 104 - 037 - 010 <br /> ------------ <br /> PHONE#2 Ext. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK if BILLING ADDRESS❑ <br /> BUSINESS NAME MAGALLON CONSTRUCTION CO. INC. PHONE# Ex-r. <br /> (209)G02 - 3 1 GG <br /> HOME Or MAILING ADDRESS FAX# <br /> P.O. BOX. 787 ( ) <br /> CITY HUGH50N STATECA ZIP 95326 <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 <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 application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, )OPERATOR/ <br /> S TE and FEDERAL laws.APPLICANT'S SIGNATURE: DATE: /Z-Z/Z:)PROPERTY/BUSINESS OWNER❑ 1VI AGER ❑ OTHER AUTHORIZED AGENT® CONTRACTOR <br /> IfAPPLIcANT is not the BrLLnyGPARTr proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the 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 ENVIRONMENTAL HEALTH DEPARTMENT 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 /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P/E: <br /> Fee Amount: Amount Paid <br /> I! Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> END 48-02-025 <br /> REVISED 11!17/2003 <br /> SR FORM(Golden Rod) <br />