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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID # SERVICE REQUEST # Gas & Food Retail �' S 0 OWNER / OPERATOR f I 41 ( CHECK If BILLING ADDRESSO Jawinder Singh FACILITY NAME JD Service Stations SITE ADDRESS 9015 1 W Walnut Grove Road Thornton 95686 Street Number Direction Street Name c1tv Zip Code HOME or MAILING ADDRESS (If Different from Site Address) same as above Street Number Street Name CITY STATE ZIP PHONE #'I EXT• APN # LAND USE APPLICATION # ( 209 ) 794- 8993 PHONE #2 EXT. BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR CHECK if BILLING ADDRESS Deborah Jones BUSINESS NAME PHONE # Exr. Elite IV Contractors 209 461 -6337 HOME Or MAILING ADDRESS FAX # 2535 Wigwam Drive Stockton CA 95205 ( 209 ) 461 -6342 CITY Stockton STATE CA zIP 95205 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 la APPLICANT' S SIGNATURE • DATE . 4/22/2021 PROPERTY / BUSINESS OWNER ❑ OPERATO / ANAGER ❑ OTHER AUTHORIZED AGENT ® Administrative Assistant If APPLICANT is not the BILLING PART); 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 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 my representative. TYPE OF SERVICE REQUESTED: T COMMENTS : ACCEPTED BY: // EMPLOYEE #: DATE: 2 �r ASSIGNED T0 : C� �� EMPLOYEE M n DATE: Date Service Completed ( if already completed) : SERVICE CODER PIE: Fee Amount: Amount Paid , �� Payment Duate 2 Payment Type Invoice # Check # 23� � Received By : FHn 48-02-02.5 SR FORM (Golden Rod)