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t SAN JOAQUIN COUNTY ENVIRONMENTAI, HEAL'T'H DEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID # SERVICE REQUEST # Convenience stare with fuel facility I OWNER/ OPERATOR ARCO AMIPM Trinity Parkway CHECK Kerr Dharni HOME or MAILING ADDRESS if BILLING ADDRESS FACILITY NAME 6698 Mack Road SAN JOAQUIN COU ARCO AM/PM Park wa Sacramento STATE CA zip 95821 SITE ADDRESS HEALTH DEPARTME T 1Trinit 10715 TrinityParkway I Y Stockton ASSIGNED TO: wF I i {q 95279 Street Number Direction Street Name City zip Code HOME or MAILING ADDRESS (if Different from Site Address) Fee Amount: )-A ! — Amount Paid f Payment Date 6698 Street Number Mack Road Street Name CITY Sacramento STATE CA zip 95821 PHONE41 EXT. ( 916 ) 715-6425 APN # 6602002 LAND USE APPLICATION # P16-0051 PHONE#2 Ezr. t ) BOS DISTRICT LOCATION CODE CONTRACTOR 1 SERVIC'F RFOI lFCT"P REQUESTIO t ChecL 1 t Ken Dharni CHECK if BILLING ADDRESS BUSINESS NAME PHONE # Ezr. ARCO AMIPM Trinity Parkway 916 715-6425 HOME or MAILING ADDRESS FAX # 6698 Mack Road SAN JOAQUIN COU t ) Sacramento STATE CA zip 95821 rsaL Lust. A%_KNUWL@ MlKMLN-1': I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project specific ENVIRONMENTAL. HRALTII 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 JOAi,IUIN COI IN'rY Ordinance Codes, Standards, STAT[: and FI D[ -RAI. laws. APPLICANT'S SIGNATURE: r'RO!'ERI I'! 13 t'$INFSS O�5'�'ER® OPERATOR! MANAGER ©` OTHER AUTHORIZEo A(;r:N-r 1 .'1PPLIC:AA'T is not the BILLING P.dRTY, Proofof authorizatio+r 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 ail results, geotechnical data and/or environmental/site assessment information to the SAN JOAQOIN COUNTY ENVIRONMENTAL. HEALTH Dt-:PART EN7 as soon as it is available and at the same time it is provided to me or my representative. TYPE OF SERVICE REQUESTED: � f )a i ChecL 1 t PAYMENT COMMENTS: SEP�2 0 2016 SAN JOAQUIN COU ENVIROMENTAL HEALTH DEPARTME T ACCEPTED BY: �G EMPLOYEE #: DATE: ASSIGNED TO: wF I i {q EMPLOYEES: DATE: a Date Service Completed (if already completed); SERVICE CODE: 5 21 PIE: 0 Fee Amount: )-A ! — Amount Paid f Payment Date Payment Type invoice # Check # ReceivedBy: I EHD 48-02-025 REVISED 1111712003 SR FORM (Golden Rod)