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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # SERVICE REQUEST # <br /> Gas Station r 190002 e7�5 S � COSH 092 <br /> OWNER / OPERATOR <br /> Gurpreet Randhawa CHECK If BILLING ADDRESS <br /> FACILITY NAME ARCO <br /> SITE ADDRESS 1329 Escalon Ave. Escalon 95320 <br /> Street Number Direction Street Name City Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE #1 EXT. APN # LAND USE APPLICATION # <br /> PHONE #2 EXT, BOS DISTRICT LOCATION CODE <br /> ( ) ® C) L4 0 . <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR John Baylis CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE # EXT. <br /> IEC Services 916 993-6312 <br /> HOME or MAILING ADDRESS FAX # <br /> 4901 Warehouse Way , ( ) <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 or <br /> activity will be billed to me or my business as identified on this form . <br /> 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. <br /> APPLICANT' S SIGNATURE : S DATE : 8/ 16/21 <br /> PROPERTY / BUSINESS OWNER ❑ OPE TOR / MANAGEV ❑ OTHER AUTHORIZED AGENT ® Contractor <br /> If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION : When applicable , I , the owner or operator of the property located at the above <br /> site address , hereby authorize the release of any and all results , geotechnical data and/or environmental/site assessment information <br /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as Soon as It IS available and at the same time It IS provided to me or <br /> my representative . <br /> TYPE OF SERVICE REQUESTED : <br /> COMMENTS : C ) i <br /> AUG 16 V 4 <br /> SAN ,,OZ02, <br /> q <br /> NEA TH p00 COLINT <br /> ACCEPTED BY : a / f� Yjj EMPLOYEE # : DATE : <br /> ASSIGNED TO : Aro` t EMPLOYEE # : DATE : <br /> Date Service Completed (if already completed) : SERVICE CODE : �9 (►i . /J�� PIE : �8 <br /> Fee Amount: ' coo Amount Paid � Paymenuut Date F1114 <br /> Payment Type Invoice # Check # Received By : <br /> EHD 48-02-025 SR FORM (Golden Rod) <br /> 07/17/08 <br />