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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FAC��IL19ITY ID# SERVICE REQUEST# <br /> Convenient Store with Gas <br /> S`"IC <br /> OWNER/OPERATOR <br /> Kufit Kaur Gill and Sital Gill CNECKIf BILLING ADDRESS <br /> FACILITY NAME <br /> Quik Stop Market#551121 <br /> SITE ADDRESS Manteca <br /> 1196 W.Street Number Diracaon Louise Aven Street Name CI 9Z33 <br /> Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> 165 Flanders Rd., Flanders Rd. <br /> SheetNumber Street Name <br /> CITY STATE ZIP <br /> Westborough MA 01581 <br /> PHONE#1 E t. APN# LAND USE APPLICATION# <br /> ( 508 ) 270-4401 217410430000 <br /> PHONE#2 EXr• SOS DISTRICT LOCATION CODE <br /> 1 925-) 336-1596 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR Vicky Cassell <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAMEQuik Stop Markets, IDC. PHONE# ExT. <br /> 925y 336-1596 <br /> HOME or MAILING ADDRESS FAX# <br /> 38995 Farwell Dr. ( ) <br /> CITY Fremont STATE CA ZIP 94536 <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. A� nn � S loop , �-yt <br /> APPLICANT'S SIGNATURE: y�Cte� GAS DATE:03/17/2021 <br /> Et <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZEDAGENT L10yFranchise Manager <br /> /fAPPLICANT 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 <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 andat talc same time it is <br /> provided to me or my representative. I"H YM <br /> TYPE OF SERVICE REQUESTED: N r2lNclil tZ -P I VE <br /> COMMENTS: P <br /> Retail Market 1000 SQ/FT with Food Prep SAN R ? X021 <br /> ENVIRON/N COUNTI <br /> HEALTH DE ARTMENT <br /> ACCEPTED BY: - �L,e� EMPLOYEE M DATE: 2 i <br /> ASSIGNED TO: r� �� EMPLOYEE#: DATE: .q <br /> Date Service Completed (if already complet SERVICE CODE: �(p PIE: llie:�O Z <br /> Fee Amount: SZ Amount Paid �Sa'6D Payment Date 1,Z <br /> Payment Type Invoice# Check# /Z 3(a Received By: <br /> EHD 48-02-025 C. c L' _, r/a+o.'ir'a a^ •(aSR FORM(Golden Rod)_ <br /> REVISED 11/17/2003 t zoo CA-,;5 Gf S� <br /> Q�b �l�IZ2� <br />