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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # SERVICE REQUEST # <br /> Retail Gasoline Facility WN, <br /> OWNER / OPERATOR Mushtaq Omar <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME SB Gas and Market <br /> SITE ADDRESS 515 S W 11th St Tracy 95376 <br /> Street Number Direction I Street Name City Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) Same <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE #1 EXT. APN # LAND USE APPLICATION # <br /> ( ) <br /> PHONE #2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR Mushtaq Omar <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME Tank Tight systems , Inc . PHONE # <br /> ONE # 432 -5211 EXT. <br /> HOME or MAILING ADDRESS FAX # <br /> 515W11thSt ( ) <br /> CITY Tracy STATE CA ZIP 9376 <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 : — DATE : 07/14/2023 <br /> PROPERTY I BUSINESS OWNER ® OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT IS not the BILLING PARTY, proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION : When applicable , I , 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 It Is provided t0 me or <br /> my representative . <br /> PAYMtNi <br /> TYPE OF SERVICE REQUESTED : 61/1 � /�� RECEIVED <br /> COMMENTS : ` l (��2 <br /> JUL 17 202 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY : r �+�J/ � � � �� EMPLOYEE # : DATE: �7 /4/25 <br /> EMPLOYEE # : DATE: <br /> ASSIGNED TO : 7711y Z3 <br /> Date Service Completed ( if already completed ) : SERVICE CODE : /� 9 > PIE : <br /> Fee Amount: .f Gf F&7 Amount Paid Payment Date <br /> Payment Type Invoice # C c # S` q l Received By : <br /> �Vl ) m I <br /> U /r,« A=) oldtzziy7 �O ?� Z ?j <br /> EHD 48-02-025 Q 19e'?YU SR FORM (Golden Rod) <br /> 07/ 17/08 <br />