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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Gasoline Service Station <br /> OWNER/OPERATOR <br /> DN Partners, LLC. CHECK If BILLING ADDRESS El <br /> FACILITY NAME C-Store w/ 76 Fuel Island <br /> SITE ADDRESS 141 E Harney Ln. Lodi 95240 <br /> Street Number I Direction I Street Name city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 10940, C-274 Trinity Parkway <br /> Street Number Street Name <br /> CITY Stockton STATE CA ZIP 95219 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> ( 916) 807-4076 062-410-35 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> Mel Higginbotham CHECK If BILLING ADDRESS <br /> BUSINESS NAME PM Design Group, Inc. PHONE# EXT. <br /> 530 303-2814 <br /> HOME or MAILING ADDRESS FAx# <br /> 6930 Destiny Drive, Suite 100 ( ) <br /> CITY Rocklin STATE CA ZIP 95677 <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 d FED L laws. <br /> APPLICANT'S SIGNATURE: DATE: f I <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> If APPLICANT is not the BILLING 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 COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: RECEIVED <br /> COMMENTS: <br /> JUL 19 2018 <br /> ENVIRONMENTAL HEALTH <br /> PERMIT/SERVICES <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P 1 E: <br /> Fee Amount: Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />