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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # SERVICE REQUEST # <br /> o � x - � } <br /> OWNER / OPERATOR <br /> GUlbahar Salnl CHECK If BILLING ADDRESS <br /> FACILITY NAME Grappa Market Shell <br /> SITE ADDRESS 710 N Jacktone Rd Ripon 95366 <br /> Street Number Direction Street Name City Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 14151 <br /> Grappa Investments Street Number Newport Ave . Ste 203 Street Name <br /> CITY Tustin STATE CA ZIP 92780 <br /> PHONE #1 EXT, APN # LAND USE APPLICATION # <br /> ( 312 ) 912 - 1833 <br /> PHONE #2 ExT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> James Otto CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE # ExT. <br /> LC Services 559 444 - 1730 <br /> HOME or MAILING ADDRESS 3887 N Valentine Ave FAx # <br /> CITY Fresno STATE CA ZIP 93722 <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 and FEDERAL laws . <br /> APPLICANT ' S SIGNATURE : 12,Lv DATE : 1 /21 /2022 <br /> PROPERTY / BUSINESS OWNER ❑ OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT ® Project Coordinator <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 above <br /> site address , hereby authorize the release of any and all results , geotechnical data and/or environmental/site assessment information <br /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the Same time itvided to me or <br /> my representative . I rM <br /> TYPE OF SERVICE REQUESTED : EE'V ��� c AE / <br /> COMMENTS : EB ' 0 <br /> SqN J ?O2? <br /> Oq <br /> NSA TN <br /> 1146�lv ' /V <br /> MENT <br /> ACCEPTED BY : \ V%�� EMPLOYEE # : DATE : 1 �� <br /> ASSIGNED TO : N4 EMPLOYEE # : DATE:Date Service Service Completed (if already completed) : SERVICE CODE : V \/i-, PIE`: \Z�� <br /> v �/ 1 <br /> Fee Amount: �J � �\ C) Amount Pa ' 3 oz746. U� Payment Date 521 2� <br /> Payment Type Invoice # Check # ' 3ff 7. 3 eceiv d By : <br /> EHD 48-02-025 SR FORM (Golden Rod) <br /> 07/17/08 <br />