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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # SERVICE REQUEST # <br /> Fuel dispensing station A N .1 Qoe),q <br /> OWNER / OPERATOR <br /> Avin Shaan Investments , LLC CHECK If BILLING ADDRESS ❑ <br /> FACILITY NAME <br /> Harney Lane 76 <br /> SITE ADDRESS <br /> 141 E Harney Lane Lodi <br /> Street Number DirectIon treat Na a City Z113 Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> 5453 COSUmnes Dr . Street Number StreetName <br /> CITY Stockton STATE CA zip 95219 <br /> PHONE #1 EM APN # LAND USE APPLICATION # <br /> (209) 518-3496 <br /> PHONE #2 EXT , BOS DISTRICT LOCATION CODE <br /> ( <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> Margaret Smith CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE # ExT• <br /> 8Z Maintenance 916 371 -2380 <br /> HOME or MAILING ADDRESS FAX # <br /> PO Box 933 ( ) <br /> CITY W Sacramento STATE CA Zip 95691 <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 : 1 /22/22 <br /> r , <br /> PROPERTY / BUSINESS OWNER 0 OPERATOR / MANAGER OTHER AUTHORIZED AGENT 0 <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 i5 available and at the Same time it IS provided t0 me Or <br /> my representative . <br /> TYPE OF SERVICE REQUESTED ; 1 ' o ht P� A <br /> III! <br /> COMMENTS: <br /> SA At <br /> H�q THIO/V Al UN7Y <br /> ACCEPTED BY : _ '��'` v EMPLOYEE # : �, y"� 1 DATE: 206rL <br /> j <br /> ASSIGNED TO : t / EMPLOYEE #: O� DATE: 1 20 Z2x <br /> Date Service Complet d (If air ady Completed) : SERVICE CODE: ' CA <br /> PIE : 8 <br /> Fee Amount ; � C5 Amount Paid �� �U Payment Date <br /> Payment Type LlInvoice # Check # — Received By : <br /> EHD 48.02 -025 <br /> 07117/08 SR FORM (Golden Rod) <br />