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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# C S//��SERVIICyI� 7E REQUEST <br /> T# <br /> Conveneint Store with Gas Station R60 7 <br /> OWNER/OPERATOR <br /> Navpreet 1/Valia Corporation CHECK if BILLING ADDRESS <br /> FACILITY NAME <br /> SITEADDRESSg 95240 <br /> 1721 Cherokee Lande Ste. 1 , Lodi <br /> Street Number Direction Street tJame Ci Zip Code <br /> HOME or MAILING ADDRESS (if Different from Site Address) <br /> 3690 Street Number Brookview Dr. Street Name <br /> CITY Stockton CA ZIP 95240 <br /> PHONE#1 EXT' APN# LAND USE APPLICATION# <br /> (209) 240-1708 062-060-480-000 <br /> PHONE ITL EXT' BOIS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> Vicky Cassell CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE# ExT' <br /> Quik Stop Market#551152 925036-1596 <br /> HOME or MAILING ADDRESS FAX# <br /> 165 Flanders Rd. ( ) <br /> CITY Westborough STATE MA Zip 01581 <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,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: yGO�.[J DATE: 04/07/2022 <br /> $R6PEl2TY7'JUS'a.ESS$wNERB 9PERAT /MANAGER ❑ OTHER AUTHORIZED AGENT Franchise Manager <br /> /,fAPPLICANT 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. /�w <br /> TYPE OF SERVICE REQUESTED: M <br /> COMMENTS: y�D <br /> 1120� <br /> 22 <br /> ME CTNQ�pMEN U 7j <br /> ACCEPTED BY: Vidal PedraZa EMPLOYEE M 6213 DATE: <br /> ASSIGNED TO: Darla AfonSkaia EMPLOYEE#: 9825 DATE 4-8-22 <br /> Date Service Completed (if already completed): SERVICE CODE: 061 P I E: 1602 <br /> Fee Amount: 152 Amount Pa' �S�-00Payment Date �Z <br /> Payment Type .Sw Invoice# 77 <br /> Check# '/-�- g(� �� Recei ed By: <br /> EHD 48-02-025 payment confiramtion # 141864062 e SR FORM(Golden Rod) <br /> REVISED 11/17/2003 Fpf� IU Z/ uo <br />