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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID # SERVICE REQUEST # Gasoline Dispensing FacilityU�� CHECK If BILLING ADDRESS BUSINESS NAME QV PHONE# OWNER I OPERATOR Daljit Singh DBA Pershing Gas 4 Less ASSIGNED T0: ' /i CHECK If BILLING ADDRESS❑ FACILITY NAME HOME or MAILING ADDRESS DATE: FAX# Pershing Gas 4 Less CODE; ( 661) 587-9758 CITY Bakersfield SITE ADDRESS 4445 Street Number N Direction Payment Date lb Pershing Avenue Street Name Invoice # Stockton City �� 95207 Zip Code HOME or MAILING ADDRESS (If Different from Site Address) Same as Above Street Number Street Name CIN STATE ZIP PHONE #1 EXT. APN # LAND USE APPLICATION # ( 209) 477-8004 PHONE #2 EXT• BOS DISTRICT LOCATION CODE CONTRACTOR /SERVICE REQUESTOR REQUESTOR Janelle Dockham CHECK If BILLING ADDRESS BUSINESS NAME PHONE# Exr, Confidence UST Services ASSIGNED T0: ' /i 661 631-3870 HOME or MAILING ADDRESS DATE: FAX# 2209 Zeus Court CODE; ( 661) 587-9758 CITY Bakersfield STATE CA zip 93308 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 perf ormed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, Standards, STATE and FEDERAL IaWs. APPLICANT'S SIGNATURE: gaw4Z 4/7 C06 DATE: 11/09/2021 PROPERTY/ BUSINESS OWNER ❑ OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGEN r ❑ Permit Clerk /f 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 as essment information t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It is available and at the same time III�tI ed to me or my representative, A A l �6 .a TYPE OF SERVICE REQUESTED: t( CZ Ice � VPA EHD 48-02-025 SR FORM (Golden Rod) 07/17/08 COMMENTS: V H q N /Ro u/ C2o?, THD pqR TOq�NTY MENT ACCEPTED BY: n ra ��► CJ EMPLOYEE #: DATE: ASSIGNED T0: ' /i EMPLOYEE M DATE: Date Service Completed (if already completed): SERVICE CODE; PI E: Fee Amount:F ot`t� Amount Paid tIC r Payment Date lb Payment Type ',5�, Invoice # Check # �3 �� eceived By: EHD 48-02-025 SR FORM (Golden Rod) 07/17/08