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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID # SERVICE REQUEST # Gasoline Dispensing Facility OWNER / OPERATOR A ` CHECK If BILLING ADDRESS DALJIT SINGH DBA PERSHING GAS 4 LESS FACILITY NAME PERSHING GAS 4 LESS SITE ADDRESS N PERSHING AVE STOCKTON 95207 4445 Street Number Direction Street Name City Zip Code HOME or MAILING ADDRESS (If Different from Site Address) (SAME AS ABOVE ) Street Number Street Name CITY STATE ZIP PHONE #1 EXT, APN # LAND USE APPLICATION # ( 209 ) 477-8004 PHONE #2 ExT. BOS DISTRICT LOCATION CODE ( ) CONTRACTOR / SERVICE REQUESTOR REQUESTOR CHECK if BILLING ADDRESS JANELLE DOCKHAM BUSINESS NAME PHONE # ExT, CONFIDENCE UST SERVICES , INC . 661 631 -3870 HOME or MAILING ADDRESS FAX # 16250 MEACHAM ROAD ( 661 ) 587-9758 CITY STATE ZIP BAKERSFIELD CA 93314 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 : 14k aAyz<t� FOR JANELLE DOCKHAM DATE : 07/30/19 PROPERTY / BUSINESS OWNER ❑ OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT ® PERMIT CLERK 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 t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the same time It IS provided t0 me Or my representative . pp //��vvpp��pp TT TYPE OF SERVICE REGtULS�LM�� tfATION PERMIT - REPLACE DISPENSERS , RELOCATE ( 1 ) DISPENSP,� COMMENTS : JUL 3 1 2099 X019 SAN JOAQUIN COUNTY EIRONMENTAL HEALTH DEPARTMENT ENVIRONMENTAL HEAL mH ACCEPTED BY: /7 �� EMPLOYEE 10 D PARTMENT ASSIGNED TO : /U 5 0 EMPLOYEE #: DATE: Date Service Completed ( if already completed ) : SERVICE CODE : / PIE : milk I Fee Amount: � ,�� Amount Paid , Payment Date Payment Type �K Invoice # Check # /SY3 7 Receiv d By : EHD 48-02-025 SR FORM (Golden Rod) 07/17/08 I