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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property F CILITY ID SERVICE REQUEST# <br /> Gas Station &Convenience Store S� Q71 1� <br /> OWNER/OPERATOR <br /> Veera Oils. Inc. CHECK If BILLING ADDRESS <br /> FACILITY NAME Hammer Lane Vitiate-82520 <br /> .SITE ADDRESS Hammer Lane Stockton 95219 <br /> 3304 <br /> Sheet Number pirewc0on treat ae Ci ZipCode <br /> HOME or MAILING ADDRESS (If Different from Site Address) 38719 Delphinium Cf. <br /> Street Number Street Name <br /> Clio Newark STATE CA ZIP 94560 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (408 ) 464-0179 <br /> PHONE#2 EXT• BOIS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REOUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> HOME or MAILING ADDRESS FAX# <br /> CITY STATE ZIP <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 <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,STATEand FEDERAL laws. <br /> APPLICANT'S SIGNATURE: /vTE/'/ " �. DATE: 01/13/22 <br /> PROPERTY/BUSINESS OWNERO OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ President <br /> If APPLICANT is not the BILLING PARTY proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, 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 environme I site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and alolw�xq�{t,is <br /> provided to me or my representative. RE 1 f11/ <br /> TYPE OF SERVICE REQUESTED: Food Permit Inspection <br /> COMMENTS: 2022 <br /> Change of Ownership occured on 1211721.New Food Permit Inspection Requested, SAN <br /> OA(�(I/N CCU[[ <br /> HEALTI RDEPASNI'AL <br /> ACCEPTED BY: EMPLOYEE#: DATE: 1 13 2y <br /> ASSIGNED TO: I 1 EMPLOYEE#: 4. DATE: ' 1-j <br /> Date Service Completed (if already completed): SERVICECODE: <br /> Fee Amoun : D Amount Paid �D Payment Date 3 2 Z <br /> Payment Type Invoice# Check# /37344512- I Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />