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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Convenience Store F�co 1 ':6!50 '&f Co S J a <br /> OWNER/OPERATOR B & G Group / Mr. Hardeep Gill CHECK If BILLING ADDRESS® <br /> FACILITYNAME FAST LANE CENTRAL VALLEY <br /> SITEADDRESS 116 ROTH ROAD LATHROP 95330 <br /> Street Number Direction I Street Name city Zip Code <br /> HOME Or MAILING ADDRESS (if Different from Site Address) 111 Healdsburg Ave <br /> Street Number Street Name <br /> CITY Healdsburg STATE ZIP <br /> CA 95448 <br /> PHONE#1 Em. APN# LAND USE APPLICATION# <br /> (707 ) 431-3510 196-020-20 <br /> PHONE#2 En. BOS DISTRIU_ LOCATION CODE <br /> ( ) coo C)II <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR Mr. Muthana Ibrahim <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME M I Architects, Inc. PHONE# Ezr. 1 <br /> (925)287-1174 <br /> HOME or MAILING ADDRESS FAX# <br /> 2221 Olympic Blvd., Suite 100 ( 925)878-9875 <br /> CITY Walnut Creek STATE CA ZIP 94595 <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,Standards and FEDERAL laws. <br /> G Har Gill <br /> APPLICANT'S SIGNATURE: up / r. DATE: September 23,2019 <br /> PROPERTY/BUSINESS OWNER® OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> if APPLICANT is not the BILL/NG PARTY proof of authorization to Sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, 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/ ite assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at tth me it is <br /> provided to me or my representative. ___ ��•YYY/�F <br /> V. <br /> TYPE OF SERVICE REQUESTED: P VZ` <br /> COMMENTS: <br /> s'a'►'✓ 2419 <br /> h 0�IMNeV?,qi <br /> Hp <br /> ACCEPTED BY: EMPLOYEE#: DATE: I Q <br /> ASSIGNED TO: EMPLOYEE#: DATE: A l' 1 <br /> Date Service Completed (if already completed): SERVICE CODE: 5 2 PVI E: 1(0() <br /> Fee Amount: tl 5 Amount Paid 4S/ ob Payment Date <br /> Payment Type �L Invoice# Check#33 93 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />