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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or PropertyRECEi <br /> ®FACILITY ID# SERVICE REQUEST# <br /> Gas Station (pt -j900 '7 Fj J G7 <br /> OWNER/OPERATOR <br /> Harshad Patel D E C 2 3 2017 CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> ARP Mini Mart PKIVIPONINAFNIA1 HEALTH <br /> SITE ADDRESS !_% }UkObTs Road Tracy 95377 <br /> 25775 Street Number Direction Street Name City Zip Code <br /> HOME or MAILING ADDRESS (if Different from Site Address) Balentine Drive Suite 370 <br /> 39899 Street Number F Street Name <br /> CI STATE <br /> CARTE 94560 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (510 )600-3360 a V`1 _ 80,0 N <br /> PHONE#2 EXT. BOS DISTRICTCATION CODE <br /> (510 ) 677-4467 F <br /> J' 6( <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR Nick Patel <br /> CHECK If BILLING ADDRESSNI <br /> BUSINESS NAME Fuel Systems Consulting PHONE# EXT. <br /> 510 677-4467 <br /> HOME or MAILING ADDRESS FAX# <br /> 39899 Balentine Drive, Suite 370, ( ) <br /> CITY Newark STATE CA ZIP 94560 <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 /> APPLICANT'S SIGNATURE: A. DATE: 12/23/17 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT Project Manager <br /> ff APPLICANT is not the BILLING PARTY_proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, 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 saillle it is <br /> provided to me or my representative. '1n/p'? <br /> / <br /> TYPE OF SERVICE REQUESTED: u -1 'v COMMENTS: IVSR Q41, ? �,' <br /> MOl <br /> F^,T <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: FF✓✓'"'' EMPLOYEE#: DAT <br /> Date Service Completed (if already Completed): SERVICE CODE: Q P h: Z <br /> Fee Amount: )l Amount Paid (�(Z Payment Date <br /> Payment Type�itS�gC�,c� Invoice# Ch k# 65�.5'ttcT Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />