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f <br />I San Joaquin County Environmental Health Department <br />Lousie Ave <br />Street Name <br />Street Number <br />StateCity <br />Ext.Land Use Application #APN # <br />Ext.Location CodeBOS District <br />CONTRACTOR / SERVICE REQUESTOR <br />•Contractor TBD <br />Ext. <br />) <br />z,p 91505Burbank <br />APPLICANT’S SIGNATURE: <br />Type of Service Requested: Plan review for food service <br />Comments: <br />electronic <br />Vidal Pedraza Employee#: 6213Accepted By: <br />1-11-23Date:Employee #:Assigned to:Kadeanne Linhares <br />Date Service Completed (if already completed):523 <br />468Fee Amount: <br />Payment Type Check #Invoice # <br />payment 154591870 <br />Rhone #2 <br />( ) <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 />EHD 48-02-025 <br />REVISED 11/17/2003 <br />Owner / Operator <br />Maverik, Inc <br />Type of Business or Property <br />Gas Station <br />Phone #1 <br />( 312) 956-4092 <br />Requestor <br />Leif Erickson (Agent) <br />E <br />Direction <br />95330 <br />Zip Code <br />SR FORM (Golden Rod) <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 Depart ment hourly charges associated with this project <br />or activity will be billed to me or my business as identified on this form. <br />Amount RaicL^P <br />Business Name <br />Lampert Group LLC <br />Home or Mailing Address <br />4400 W Riverside Dr., #110-2222 <br />City <br />Facility Name <br />Maverik Gas Station <br />Site Address <br />SERVICE REQUEST <br />FACILITY id # <br />Phone # <br />_______( 312 )956-4092 <br />Fax# <br />____L <br />State CA <br />410 <br />_____________________Street Number <br />Home or MAILING Address (If Different from Site Address) <br />4589 <br />Service Code: <br />Street Name <br />Zip <br />Payment Date <br />Lathrop, CA <br />City- <br />Check if Billing Address O <br />SERVICE REQUEST# <br />Check if Billing Address I—1 <br />______________________________ Date: 12/22/21________________ <br />Property / Business Owner Operator / Manager Other Authorized Agen Agent for Owner <br />if Applicant is not the Hn.LlNC 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 <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 Count y Environmental Health Department as soon as it is available and at the same time it is <br />provided to me or my representative. x <br />s Jj4'* ' I <br />Date: 1-11-23 <br />P/E: 1601 <br />Received By: /Z