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�b SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> B, A2 C-Store with Fast Food F� 0013430 S R 00 &Co 04 a <br /> OWNER/OPERATOR <br /> Love's Travel Stops and Country Stores, Inc. CHECK if BILLING ADDRESS <br /> FACILITY NAME Love's <br /> SITE ADDRESS 1553 Colony Rd. Ripon, CA95365 <br /> Street Number Direction Street Name Cit Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#'l EXT. APN# LAND USE APPLICATION# <br /> (602 ) 738-1039 Larry Nelson <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR TBD CHECK if BILLING ADDRESS O <br /> BUSINESS NAME PHONE# EXT. <br /> HOME or MAILING ADDRESS FAX# <br /> CITY STATE ZIP <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, STATE and FEDERAL laws. 'ff / / r�r, j <br /> APPLICANT'S SIGNATURE: Myrna Smith DATE: 11-14-22 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT aermit Coordinator for <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required BRR Arc i tecttnye, Inc. <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 /> Arby's Reimage electronic <br /> ACCEPTED BY: Vidal Pedraza EMPLOYEEM C213 DATE: 11-14-22 <br /> ASSIGNED TO: Gehane Fahmy EMPLOYEE M 8788 DATE: 11-14-22 <br /> Date Service Completed (if already completed): SERVICE CODE: 523 PIE: 1601 <br /> Fee Amount: $468.00 Amount Paid $468.00 Payment Date 11-14-22 <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 payment 152832379 S RM(Golden Rod) <br /> REVISED 11/17/2003 <br />