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"AIN J"AVUIN I,OUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />Type of Business or, Property <br />SERVICE REQUEST <br />Gas Station With Convenience Store L <br />OWNER I OPERATOR <br />Daljit Singh <br />FAclury NAME <br />PershingGas For Less <br />SREADOREss 4445 <br />s<,a .m _- _ N Pershing Ave <br />FACILITY ID # SERVICE REQUEST# <br />590670'50�� <br />CHECKif BILLING ADORES <br />Stockton 95207 <br />svee[Name C 9 Coda <br />HOME Or MAILING ADDRESS (If Different from Ske Address) <br />991 Las Palmas Dr <br />Crry Street Numtrer Street Name <br />Santa Clara STATE CA ZIP 95051 <br />( 209) )ONE E".- APN 0 LAND USE APPLICATION# <br />209 7-8004 ' 0 � o <br />PHONE#2 Ezr <br />( 408) 515-0000 Bos DISTRICT Loc? COOS <br />CONTRACTOR / SERVICE REQUESTOR <br />REOUESTOR <br />BUSINESS NAME <br />HOME or MAILING ADDRESS <br />Gas For Less <br />991 Las Palmas Dr <br />FAX# <br />CHECKif BILLING ADORESSO <br />Far. <br />Cm, I , <br />Santa Clara SPATE CA LP 95051 <br />BILLING ACKNOWLEDGEMENT_ L 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, Stmtdards, Tale nd F �t laws - <br />APPLICANT'S <br />APPLICANT'S SIGNATURE: 0 12/21/2016 <br />PROPERTY /BUSIXE.Ss OWNERIT <br />DATE: OPERATOR/MANAGER 13 OTHER AUTHORIZED DATE: <br />Owner <br />6(-APPL/CANrisantlhOBIl.L1NGP.4R71 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 environmentallsite 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 representatives.-- I /-� T <br />TYPE OF SEANCE REQUESTED: b-T->rV-I ( j� n C <br />NEHTs: <br />DEC' 2 S 2016 <br />hange Of ownership. <br />JOAQUIN COUNTY <br />[AccEPTED <br />SAN <br />ENVIROMENTAL. <br />HEALTH DEPARTMENT <br />BY: <br />EMPLOYEE#: <br />DATE: <br />a1Nr5ChLdz GNED TO: <br />EMPLOYEE#: <br />DATE: <br />Date Service Completed (if already completed): <br />SERVICE CoOe <br />I <br />a r <br />Fee AmOUnIt Amount Paid <br />' r� CJ <br />\ 3 � Payment Date <br />P/E: )�ba <br />Payment Type (C_ Invoice # <br />Cheek # <br />/ 7� _ a <br />Received <br />By: .�> <br />EHD 48-02-025 <br />REVISED 11/17/2003 <br />NW <br />SR FORM (Golden Rod) <br />