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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property BUSINESS NAME FACILITY ID # HOME or MAILING ADDRESS SERVICE REQUEST # New Gasoline Dispensing Facility and Market ACCEPTED BY: Vidal Pedraza EMPLOYEEM 6213 DATE: 6_11_21 %!vmy-37 469 OWNER/ OPERATOR DATE: 6-11-21 Date Service Completed (if already completed): Safeway Inc. SERVICE CODE: 523 CHECK If BILLING ADDRESS FACILITY NAME Fee Amount: 456 Amount Paid Safeway 0055 Fuel Payment Date 2 - SITE ADDRESS 19533 South eck # Mountain House Parkway Mountain House 95391 Street Number Direction Street Name city Zip Cod. HOME or MAILING ADDRESS (if Different from Site Address) 5918 Stoneridge Mall Road Street Number Street Name CITY STATE ZIP Pleasanton CA 94588 PHONE #I Exr. APN # LAND USE APPLICATION # ( 925)226-5754 254-550-30 PA -1900293 PHONE #2 Exr• I ) BOB DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR CHECK if BILLING ADDRESS BUSINESS NAME PHONE # EXT• HOME or MAILING ADDRESS FAx# ( 1 Cm STATE ZIP BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as identified on this form. 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 COUNTY Ordinance Codes, Standards, STATE and FEDERAL laws. APPLICANT'S SIGNATURE: A 'Yis?�l� DATE: June 6, 2021 PROPERTY/BUSINESS OWNER❑ OPE 4TOR/MANAGER❑ OTHER AUTHORIZED AGENT® Architect Contracted by Owner If APPLICANT is not the BILLING PARTY proof of authorization to sign is required Title AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. PAYMENT TYPE OF SERVICE REQUESTED: Food Permit RECEIVE COMMENTS: JUN 14 2021 ,mN,IoAQUINCOUNTY ENVIRONMENTAL IIERLTH oo*RTMENt ACCEPTED BY: Vidal Pedraza EMPLOYEEM 6213 DATE: 6_11_21 ASSIGNED TO: Kadeanne Linhares EMPLOYEEM 4589 DATE: 6-11-21 Date Service Completed (if already completed): SERVICE CODE: 523 PIE• 1601 Fee Amount: 456 Amount Paid Payment Date 2 - Payment Payment Type A�, Invoice # eck # Recelve By: EHD 48-02-025 Payment confirmation # 126758326 SR FORM (Golden Rod) REVISED 11/17/2003