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I \� — n <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST v <br /> Type of Business or Property FACILITY ID!:::] SERVICE REQUEST# <br /> Convenience Store <br /> OWNER I OPERATOR Valley Fuels, Inc. /Har reet Sin h&Varinder Pal Singh <br /> CHECK if BILLING ADDRESS <br /> FACILITY NAME Edgewood Commercial Center/Valley Fuels, Inc. <br /> SITE ADDRESS 4600 S. Corral Hollow Road Tracy 95376 <br /> Street Number Direction Street Name Cit ZI Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 15E. Grantline Road <br /> Street Number Street Name <br /> CITY Tracy STATE CA ZIP 95304 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> ( 209 ) 676-0916 244-020-31 City of Tracy: #D19-0031; #CUP19-0013 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR Scott Schendel CHECK if BILLING ADOREJ3 <br /> BUSINESS NAME Schack& Company, Inc. (Project Engineer) PHONE# EXT. <br /> 209 1 835-2178 <br /> HOME or MAILING ADDRESS 1025 Central Avenue FAx# <br /> ( 209 } 835-1488 <br /> CITE` Tracy STATE CA ZIP 95376 <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 <br /> or activity will be billed to me or my business as identified on this form. <br /> I also certify that I have prepared this application a that e work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, STATE a l: D- aws. <br /> APPLICANT'S SIGNATURE: DATE: O 1 k - CA <br /> PROPERTY/BUSINESS OWNER® OPERATOR/1VIANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> #APPLICANT is not the BILLING PART}',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 <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as Soon as It is available and at the same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: lel Gl V► ch e G[L �I <br /> COMMENTS: ,�C^ <br /> 0,R V <br /> �6 <br /> ✓0 2�?> <br /> , GTyOpgR�T"'" <br /> ACCEPTED BY: xyl EMPLOYEE#: DATE: L- — _2 <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: eJ Z P t E: rl <br /> Fee Amount: qc Amount Pai Payment Date )(O V <br /> Payment Type Invoice# Check# Receive By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />