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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 �A (,� (� ® <br /> OWNER / OPERATOR <br /> Karan Pahwa CHECK If BILLING ADDRESS <br /> FACILITY NAME ARCO Cherokee Gas & Mart <br /> SITE ADDRESS 900 S Cherokee Lane Lodi , CA 95240 <br /> Street Number Direction I 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 /> ( 916 ) 849-5603 y IN <br /> PHONE #2 EXT. BOS DISTRICT �� ++ '' LOCATION CODE <br /> ( 209 ) 224-8925 ODLA <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 Sacramento , STATE CA ZIP 95826 <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 /> 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. <br /> APPLICANT' S SIGNATURE : DATE : 2/ 11 /22 <br /> PROPERTY / BUSINESS OWNER ❑ O RATOR I MANAGER ❑ OTHER AUTHORIZED AGENT Manager <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 . M <br /> TYPE OF SERVICE REQUESTED : PPA ' •!E` <br /> COMMENTS : <br /> JOA <br /> SAN FEe � � 20?2 <br /> �yFA Ty P �p4E Al r <br /> AR r L <br /> ACCEPTED BY: (24 tti EMPLOYEE M DATE : <br /> ASSIGNED TO : 1 _ EMPLOYEE # : DATE : Z �t / � j,Pl Z 7 <br /> Date Service Complete (if already completed) : SERVICECODE : IC� � � Zc�` PIE' : 2 � <br /> Fee Amount : 0 iv Amount Paid Payment Date 2A0 ,9Z <br /> Payment Type � � VInvoice # Check # /3 Receiv d By : <br /> EHD 48-02-025 SR FORM (Golden Rod) <br /> 07/17/08 <br />