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APPLICANT'S SIGNATURE: <br />PROPERTY / BUSINESS OWNER 0 OPERATOR / MANAGER MI <br />W C1 1 SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST ee <br />Type of Business or Property <br />CONVENIENCE STORE <br />FACILITY ID # <br />.p.m/...0.1.10 ......' <br />I <br />SERVICE REQUEST <br />S00/110. <br />' # <br />I <br />OWNER! OPERATOR <br />MR. JIM RUBNITZ (APPLICANT) CHECK if BILUNG ADDRESS <br />FACILITY NAME MOUNTAIN HOUSE CHEVRON <br />SITE ADDRESS <br />Street Number <br />NEC OF <br />Direction <br />INTERNATIONAL PARKWAY <br />& DAYLIGHT RcirlyNa. <br />TRACY <br />City Zit) Code <br />HOME Or MAIUNG ADDRESS (If Different from Site Address) <br />17610 Street Number <br />BLANCHARD DRIVE <br />Street Name <br />CITY MONTE SERENO STATE CA ZIP 95030 <br />PHONE #1 Err. <br />( 408 ) 813-6416 <br />APN # PORTION OF <br />209-460-35 <br />LAND USE APPLICATION # <br />PHONE #2 EXT. <br />( ) <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR MR. MUTHANA IBRAHIM (MUTHANA@MIARCHITECT.COM ) CHECK if DILLING ADDRESS <br />BUSINESS NAME .. M I ARCHITECTS, INC. PHONE # <br />( 925 )287-1174 <br />Err. <br />1# <br />HOME or MAILING ADDRESS 2221 OLYMPIC BLVD., SUITE 100 <br />FAX <br />( 925 ) 943-1581 <br />CITY WALNUT CREEK STATE CA ZIP 94595 <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 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 />DATE: <br />OTHER AUTHORIZED AGENT 0 <br />11..-iPPLICAN7' is not the BILLING PARTY, proof of authorization to sign is required <br />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 />PAYMENT <br />TYPE SERVICE REQUESTED: Ntoki -(1,--01 cetce(i--y OF RECFivFD <br />COMMENTS: <br />AUG 0 3 2021 * PtIa6( e SS : 1 SAL",=gAigECNTATTY <br />HEALTH DEPARTMEN 1 <br />ACCEPTED BY: Goff Ike i$ t., 4 EMPLOYEE #: J DATE: 7--1,--1.. ( <br />ASSIGNED TO: 1,(.. f\ lip, 11( 3 EMPLOYEE #: DATE: <br />Date Service Completed (if already completed): SERVICE CODE: c---2, 13 /E: 16 0/ <br />Fee Amount: 44 --- Amount Paid 41, v s---e..„, ....._ Payment Date E /,24, 0 / <br />Payment Type t j dr . Invoice # Check # I 2,..,ti Received By: <br />EHD 48-02-025 <br /> <br />SR FORM (Golden Rod) <br />REVISED 11/17/2003