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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 15 00006 �5C� � � �j�j2 <br /> OWNER / OPERATOR <br /> CHECK If BILLING ADDRESS <br /> Karan Pahwa <br /> FACILITY NAME Cherokee Arco <br /> SITE ADDRESS 900 S Cherokee Lane Lodi 95240 <br /> Street Number Direction Street Name Cit Zi Code <br /> HOME or MAILING ADDRESS (if Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE #t EXT N # �,{,� // 'lam LAND USE APPLICATION # <br /> AP <br /> ( ) ot 1LWqw� <br /> PHONE #2 Ex-r, BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR John Baylis CHECK if BILLING ADDRESS ® <br /> BUSINESS NAME IEC Services PHONE # ExT . <br /> 650 . 969 . 9616 <br /> HOME or MAILING ADDRESS 4901 Warehouse Way FAx # <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 : 7/8/22 <br /> PROPERTY I BUSINESS OWNER ❑ OPERATOR 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 /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the same time It IS l r��i �ed to me or <br /> my representative . to c <br /> TYPE OF SERVICE REQUESTED : <br /> COMMENTS : <br /> Alt 14202 <br /> sgNJ ? <br /> A <br /> HEAT N PARTo ANT y <br /> MENT <br /> ACCEPTED BY: ' EMPLOYEE # : DATE: <br /> ASSIGNED TO : ` /t ' J /J //] EMPLOYEE # : DATE: / / <br /> Date Service Completed (i ready complete : SERVICE CODE : gd2eqr P 1 E� �� <br /> Fee Amount: LAmount Paid �j Payment Date r / <br /> Payment Type ��_ Invoice # Check # l SZ 320 Received By : <br /> EHD 48-02-025 SR FORM (Golden Rod) <br /> 07/17/08 <br />