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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # SERVICE REQUEST # <br /> Fueling Station FAI D 00 3"7l (� S ROO $ 7 7 0 0 <br /> OWNER / OPERATOR <br /> Mandeep Singh Dua CHECK If BILLING ADDRESS ❑ <br /> FACILITY NAME Super Stop <br /> SITE ADDRESS 290 N Main St . Manteca 95336 <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 #1 EXT. API # LAND USE APPLICATION # <br /> ( ) 209-2394475 <br /> PHONE #2 EXT. EMAIL BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> James Otto CHECK if BILLING ADDRESS <br /> BUSINESS NAMELC Services PHONE # EXT. <br /> ( ) 559-444- 1730 <br /> HOME or MAILING ADDRESS FAx <br /> 3887 N Valentine Ave ( ) <br /> CITY Fresno STATE CA ZIP 93722 EMAIL engineeringdivision@lcservices . com <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 activity <br /> 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 : Ya4*vve,v io DATE : 1 /31 /2024 <br /> PROPERTY / BUSINESS OWNER ❑ OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT ® Project Coordinator <br /> If APPLICANT is not the BILLING PARTY /hoof 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 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 t0 me or my <br /> representative . <br /> TYPE OF SERVICE REQUESTED : <br /> COMMENTS: / NT <br /> s FFB of �� <br /> NFgNT R NlNco e4 <br /> y �epq FN <br /> ACCEPTED BY : �aC ' lava EMPLOYEE # : DATE : ' 11 31 E NJ <br /> ASSIGNED TO : ' y 1 .moo EMPLOYEE # : DATE : 1 j3 24 <br /> Date Service Completed ( if already completed ) : - SERVICE CODE : 2W PIE : ��oq <br /> Fee Amount: 2 0C' Amount Pai Payment Date 2 <br /> Payment TypeU � s � Invoice # Check # -� � -, � Received By : <br /> EHD 48-02-025 SR FORM (Golden Rod) <br /> 03/22/23 <br />