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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # SERVICE REQUEST # <br /> RETAIL GAS STATION - ? �V 6 <br /> OWNER / OPERATOR MANDEEP DUA <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME SUPER STOP GAS & LIQUOR <br /> SITE ADDRESS 4tet. .2g6) N MAIN STREET MANTECA 95336 <br /> Street Number Direction 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 /> ( 209 ) 815 -5180 <br /> PHONE #2 ExT• BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR TONY M E H RO KE CHECK If BILLING ADDRESS ® <br /> BUSINESS NAMETANK-TIGHT SYSTEMS , INC PHONE # <br /> ONE # 667 -6891 EXT. <br /> HOME or MAILING ADDRESS FAX # <br /> 8515 WATERMAN ROAD ( ) <br /> CITY ELK GROVE STATE CA ZIP 95624 <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 /> 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 ands FEDERAL laws`. ^ <br /> APPLICANT ' S SIGNATURE : I� �U �ti \�� 1 DATE : 10/8/2021 <br /> PROPERTY / BUSINESS OWNER ❑ OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT ® CONTRACTOR <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 assessnip formation <br /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the same time It IS r� �fQ4 <br /> my representative . ` eeTT/`�C �. ���rrr�/ �` <br /> TYPE OF SERVICE REQUESTED : '�'� - - � - ' 1Orr <br /> COMMENTS : SQ /V ?O?� <br /> WE ARE REQUSTING TO REMOVE 2 SATALITE DISPENSERS AND MOVE DSL PRODUCT LIN , <br /> DISPENSERS 44T4)g M�V7�NTy <br /> MFNT <br /> ACCEPTED BY : n ` j EMPLOYEE # : DATE : O . <br /> ASSIGNED TO : I / <br /> EMPLOYEE # : DATE : lI <br /> Date Service Completed ( if already completed ) : SERVICE CODE : . f PIE : 2 W f <br /> Fee Amount: 00 Amount PaidL��� . Q � Payment Date /0/// �/ <br /> Payment Type Invoice # Check # ) 2 Received By : oe <br /> EHD 48-02-025 SR FORM (Golden Rod) <br /> 07/ 17/08 <br />