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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 i9� 000 3 ' O 9 WO 5qc <br /> OWNER I OPERATOR <br /> Paramjit Shergill CHECK If BILLING ADDRESS <br /> FACILITY NAMEBilljar Valero <br /> SITE ADDRESS 153 11 th St Tracy 95376 <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 #t 408 -204 - 1636 EXT• APN # LAND USE APPLICATION # <br /> ( ) <br /> PHONE #2 ExT• BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> Afforda Test CHECK If BILLING ADDRESS <br /> BUSINESS NAME Afforda Test PHONE # 209 - 744 - 0112 EXT. <br /> HOME or MAILING ADDRESS 416 2nd Street FAX # <br /> c ) <br /> CITY Galt STATE CA ZIP 95632 <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 an F DERAL IawS . <br /> APPLICANT ' S SIGNATURE : P4 DATE : 10/24/22 <br /> PROPERTY / BUSINESS OWNER S OPERATOR I MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <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 : S PACEIVEO <br /> COMMENTS : O � / �\ 1 2022 <br /> J SA ENVIRONME TMENT <br /> REALTN DEPAR <br /> ACCEPTED BY: � / EMPLOYEE #: DATE: /D Z7 Z 2L <br /> ASSIGNED TO : Q �J . / �j-T EMPLOYEE # : DATE: <br /> Date Service Completed ( if already completed ) : SERVICE CODE : le7f 2qS PIE : Up <br /> Fee Amount : Z/ �e Amount Paid t� f Payment Date <br /> Payment Type Invoice # TI 1�ck�# sa (7 Received By : <br /> EHD 48-02-025 SR FORM (Golden Rod) <br /> 07/ 17/08 <br />