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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 I Convenience Store � G 6/a `13 ?- SQ ( O I n `I <br /> OWNER/OPERATOR DBIL l <br /> Abdul Kohistani CHECK If BILLING ADDRESS x <br /> FACILITY NAME Excel Petroleum, Inc. <br /> SITE ADDRESS 3304W Hammer Lane Stockton 95219 <br /> Sheet Number Direction Street Name CI Zi Cade <br /> HOME or MAILING ADDRESS (if Different from Site Address) <br /> same as above Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EAT' APN# LAND USE APPLICATION# <br /> ( 209 ) 648-9990 071-200-130-000 <br /> PHONE#2 ExT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> same as above CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE# ExT. <br /> HOME or MAILING ADDRESS FAx# <br /> ( ) <br /> CITY STATE ZIP <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of some, <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. <br /> APPLICANT'S SIGNATURE: DATE: 12/3/2022 <br /> PROPERTY/BUSINESS OWNER® OPERATOR/MANAGER OTHER AUTHORIZED AGENT[3 <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 <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 and at the same time it is <br /> provided to me or my representative. PAYMENT <br /> TYPE of SERVICE REQUESTED: ah m RECEIVED <br /> COMMENTS: "�I �(., <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> 1 p0Pin we.V HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: S <br /> Date Service Compl ed (if already completed): SERVICE CODE: b / PIE: <br /> 6d <br /> Fee Amount: I /S(p Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 4a-02-025 Gpn{r/?'ia -/ -4L iS3734IJ-� �L �DZ� <br /> SR FORM(Golden Rod) <br /> REVISED 11/17/2003 /2, /r// 2,v 2, <br />