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DocuSign Envelope ID:E8069902-06FBAF56-649E-9FB6D91BOA5A <br /> JAN JUAWUIN L.UUN I Y cNVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# S RVICE REEQQUEST# <br /> Auto Fuel Gas Station with Convenience Store <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> Airport Petroleum, LLC <br /> FACILITY NAME <br /> Airport AM/PM <br /> SITE ADDRESS S Airport Way <br /> 4607 Stockton 9599�pg <br /> StroolNumber I Direction SlrootNomo City "ZI Codo <br /> HOME Or MAILING ADDRESS (If Differont from Slto Address) <br /> 2190 Straot Numbar Meridian Park Blvd,Sui a o <br /> CITY STATE zip <br /> Concord CA 94520 <br /> PHONE#1 ExT• APN# LAND USE APPLICATION# <br /> (925)446-6606 1177-460-240-000 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR CHECK If BILLING ADDRESS13 <br /> Charan'iv Dhaliwal <br /> BUSINESS NAME PHONE EXT. <br /> Airport Petroleum,LLC <br /> HOME or MAILING ADDRESS FAX# <br /> 2190 Meridian Park Blkvd. Suite G (925)446-6808 <br /> CITY Concord STATE zipCA 94520 <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 /> 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, F. i ERAL laws. <br /> APPLICANT'S SIGNATURE: I Charanjiv Dhaliwal DATE: 10/05/2023 <br /> PROPERTY/BUSINESS OWNER OPEOOCRATT OROR 7C , <br /> MAA NN AGER ❑ OTHER AUTHORIZED AGENT is <br /> If APPLICANT is not the BILLING PARTY,proof Of authorization to Sign Is r'equIred 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 to me or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED:I nstallation Of new UST System <br /> COMMENTS: <br /> System to be installed by Town & Country Contractors, Inc. DEC 15 2023 <br /> Fire Permit#23-00105 <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE M DATE: <br /> Date Service Completed (if already Complotod): SERVICE CODE: t - C' P/E: 2 35C <br /> Fee Amount: Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48.02-025 SR FORM(Golden Rod) <br /> 07/17/013 <br />