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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY IDT# SERVICE REQUEST ## <br /> gas station Fj /1 oI)() v'-'[/ [l J 5P00 afW .1+ ' <br /> OWNER / OPERATOR / / I 1. <br /> Speedway CHECK If BILLING ADDRESS <br /> FACILITY NAME Speedway <br /> SITE ADDRESS 2705 Country Club Blvd . Stockton 95204 <br /> Street Number Direction Street Name City Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE Zip <br /> PHONE #t EXT . APN # LAND USE APPLICATION # <br /> ( ) <br /> PHONE #2 Ext . EMAIL BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> • CHECK If BILLING ADDRESS <br /> BUSINESS NAME H NE - ^ 11 ExT , <br /> HOME Or MAILING ADDRESSugo Q �+ `, 'q , ^ Na <br /> E� 1 (FAX * ) <br /> CITY � L} 1 1 ZIPITD ' iL E AIL <br /> BILLING ACKNOWLEDGEMENT: I , the undersigned property or business owner, operator or authorized agent of same <br /> Lu <br /> acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity <br /> 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 & 05/ t5/23 <br /> PROPERTY / BUSINESS OWNER ❑ OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT ® Contractor <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 site <br /> address , hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information to the <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the Same time It IS provided to me Or my <br /> representative. <br /> TYPE OF SERVICE REQUESTED : <br /> UST ReU�o•yfiU7 Rsepalr —�M. inor Plan Check Permit <br /> COMMENTS: D rCPI1C^ / IQ / 7COr ,obke� M' <br /> V e <br /> MAY 152023 <br /> AEMA <br /> C� <br /> HEgLT1 D N A ' L <br /> ACCEPTED BY: ( ej7 EMPLOYEE #: DATE: 0 ,, N <br /> ASSIGNED TO : G ' z Vh Ae EMPLOYEE #: DATE : / ,� .ZZ <br /> Date Service Completed ( if already completed ) : 14 SERVICE CODE : /t?,f.07e I PI E: a/ 0e7 <br /> Fee Amount: vim. or Amount Pai D� Payment Date <br /> J <br /> Payment Type Invoice # Check # / Z 17 1 g Received By : <br /> EHD 48-02-025 SR FORM (Golden Rod ) <br /> 03/22/23 <br />