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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # SERVICE REQUEST # <br /> Gas Station FA0003726 � �— <br /> OWNER / OPERATOR <br /> A & S Partnership DBA Fast & Easy Mart 103 CHECK If BILLING ADDRESS <br /> FACILITY NAME Fast & Easy Chevron <br /> SITE ADDRESS 8660 Lower Sacramento Rd Stockton 95210 <br /> Street Number Direction I Street Name City Zin Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE #1 EXT. APN # /� LAND USE APPLICATION # <br /> ( 925 ) 925-998-7299 1� Cl X16 `3(1 u <br /> PHONE #2 EXT. v BOS DISTRIC a LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> Ronnie Lewis CHECK If BILLING ADDRESS <br /> BUSINESS NAME IEC Services Inc PHONE # EXT. <br /> 916 993 6312 <br /> HOME or MAILING ADDRESS FAX # <br /> 4901 Warehouse Way ( ) <br /> CITY Sacramento STATE CA ZIP 95826 <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 /> 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 andFEDERALlaws . <br /> APPLICANT' S SIGNATURE : Azww� e IAOI(� � DATE : 4/ 15 /2021 <br /> PROPERTY / BUSINESS OWNER ❑ OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT © Contractor <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 above <br /> site address , hereby authorize the release of any and all results , geotechnical data and/or environmental/site assessment information <br /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as Soon as It Is available and at the same time It Is provided t0 me Or <br /> my representative . <br /> TYPE OF SERVICE REQUESTED : ks /7— <br /> P<�t �tlo �7 I� �IV <br /> COMMENTS : r'1�� Aso <br /> 71>tW Cf- 1pl. 0 SAN oDl ' S 202, <br /> A�� pMENOUN <br /> Ty <br /> NT L <br /> OR <br /> ACCEPTED BY: S [ 1�?4 V -e��i EMPLOYEE # : DATE : <br /> ASSIGNED TO : I t( J EMPLOYEE # : DATE: / 5//0140( l <br /> Date Service Completed ( if already completed) : . SERVICE CODE : P / E : , <br /> Fee Amount: , Amount Pal DOO 1)� Payment Date t'S21 <br /> Payment Type VlSG-- Invoice # Check # 1 .2 <br /> Recei ed By : <br /> EHD 48-02-025 SR FORM (Golden Rod) <br /> 07/17/08 <br />