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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FAI Y >Iv�i SERVICE REQUEST# <br /> Gasoline Service Station ��� l C�0b-7 ft-7 <br /> J <br /> OWNER/OPERATOR 2011 <br /> JUL19 CHECK If BILLING ADDRESS <br /> DN Partners, LLC. <br /> FACILITY NAME C-Store w/ 76 Fuel Island -'ZiV 1RUNh'�ENT��VIE <br /> SITE ADDRESS 141 E Harney Ln. Lodi 95240 <br /> Street Number Direction Street Name City Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 10940, C-274 Trinity Parkway <br /> Street Number Street Name <br /> CITY Stockton STATE CA ZIP 95219 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> ( 916) 807-4076 062-410-35 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) 00A U� <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> Mel Higginbotham CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> PM Design Group, Inc. <br /> 530 303-2814 <br /> HOME or MAILING ADDRESS FAX# <br /> 6930 Destiny Drive, Suite 100 ( ) <br /> CITY Rocklin STATE CA ZIP 95677 <br /> BILLING ACKNOWLEDGENIENT: 1, 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 oil 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,Standards,STATE d FED 'RAL laws. <br /> APPLICANT'S SIGNATURE: DATE: -1 f(k /I <br /> tl <br /> PROPERTY/BUSINESS OWNCR❑ OPCRATOR/tV ANAGER ❑ OTHER AUTHORIZED AGEN'r ❑ <br /> i/"APPLICaNT is not the BILLING PARTY,proof of authorization:to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMA'T'ION: 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: RECEIVED <br /> JUL 10 2018 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEAUACCEPTED BY: til,n EMPLOYEE#: 6TCC "VATe:'4 M7 —i (� <br /> ASSIGNED TO: EMPLOYEE#: �JN�� DATE: �— Cj t�� <br /> Date Service Completed (if already completed): N. SERVICE CODE: O� <br /> Fee Amount: 30�C) Amount Paid 3t _ Payment Date -712-o I f g' <br /> Payment Type f Invoice# Check# D�I Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />