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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FAC qy ID <br />SERVICEREQUEST <br /># <br />Gas Station &Convenience Store <br />209 648-9990 <br />00 SW Iqq-- <br />OWNER / OPERATOR <br />6131 Pacific Ave. <br />( ) <br />Abdul Kohistani <br />CHECK If BILLINGADDRESSJ6I <br />E <br />FACILITY NAME <br />ACCEPTED BY: �' <br />Excel Petroleum - Pacific Ave. <br />EMPLOYEE <br />I <br />l <br />SITEADDRESS <br />ASsIGNEDTO: M <br />Pacific Ave. <br />Stockton <br />DATE: ' I <br />95207 <br />61$1 Street Number <br />ire <br />Dction <br />PIE: <br />Street Name <br />city <br />zip Code <br />HOME or MAILING ADDRESS (if Different from Site Address) <br />C� <br />Payment Date <br />same as above <br />Street Number <br />Street Name <br />CITY <br />STATE ZIP <br />Check #1 <br />PHONE #1 Ex . <br />APN # <br />LAND USE APPLICATION # <br />(209 1646-9990 <br />097-464-180-000 <br />PHONE #2 Ez . <br />( ) <br />BO$ DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />Abdul Kohistani CHECK If BILLING ADDRESS <br />BUSINESS NAME <br />PHONE# Ex . <br />Excel Petroleum - Pacific Ave. <br />209 648-9990 <br />HOME or MAILING ADDRESS <br />FAX# <br />6131 Pacific Ave. <br />( ) <br />CITY STATE CA ZIP 11211 <br />sto w <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: DATE: 12/2) /2022 <br />PROPERTY/BUSINESS OWNERS OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br />/fAPPL/CANT is not the BILLING PAKTT proof of authorization to sign is required <br />President <br />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. Pq <br />TYPE OF SERVICE REQUESTED: <br />�� <br />C <br />COMMENTS: <br />/`'1 <br />DEC 21 <br />Sgjo <br />ENV AQUIN <br />C <br />HEgLiy pEPART7'AL <br />ACCEPTED BY: �' <br />/ <br />r/ <br />TTT <br />EMPLOYEE <br />I <br />l <br />DATE:�a- <br />ASsIGNEDTO: M <br />EMPLOYEE <br />DATE: ' I <br />Date Service Comple d (if already completed): <br />SERVICE CODE: <br />PIE: <br />Fee Amount: <br />1 <br />Amount PaidI <br />'p <br />C� <br />Payment Date <br />Payment Type //7 . t nvoice # <br />Check #1 <br />Received By: <br />EHD 48-02-025 c 1 6 U l I cJ 4JV 1✓ L I SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />