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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Convenient Store with Gas C, c70 ICe23 q l <br /> OWNER/OPERATOR <br /> CHECK if BILLING ADDRESS❑ <br /> Makhan Singh Nijar and Gurinder Singh <br /> FACILITY NAME <br /> Quik Stop Market#551120 <br /> SITE ADDRESS Stockton 95209 <br /> 9321 N.. Thornton Rd. <br /> Street Number I Direction I Street Name Ci ZI Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> 165 Flanders Rd., Flanders Rd. <br /> Street Number Street Name <br /> CITY STATE Zip <br /> Westborough MA 01581 <br /> PHONE#1 En. APN# ® LAND USE APPLICATION# <br /> l 508) 270401 0801 50000 <br /> PHONE#2 EST• SOS DISTRIcw <br /> LOCATION CODE <br /> ( 925-) 336-1596 <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR Vicky Cassell <br /> CHECK if BILLING ADDRESS <br /> BUSINESS NAME quik Sto Markets, Inc. PHONE# EM. <br /> P 925y 336-1596 <br /> HOME or MAILING ADDRESS FAX# <br /> 38995 Farwell Dr. ( ) <br /> CITY Fremont STATE CA ZIP 94536 <br /> BILLI 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 /> 44 <br /> APPLICANT'S SIGNATURE: 1/tC DATE: 07108/2021 <br /> 07/08/2021 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT LIO Franchise Manager <br /> IfAPPLtCANT is not the BLLLHVGPARTP 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 environment%IM1lllrrnent <br /> information to the SAN JOAQUINTOUNTY ENVDtomAENTAL HEALTH DEPARTMENT as soon as it is available and at tV&WVfiPit is <br /> provided to me or my representative. ' <br /> TYPEOF SERVICE REQUESTED: lU <br /> �ENNRONMERNTM NI <br /> Retail Market 2,200 SQIFT with Food Prep REnLTHOEa <br /> ACCEPTED BY: CetTfu'e-S C,7 EMPLOYEE DATE: 0- Z( <br /> ASSIGNED TO: VN.� EMPLOYEE M DATE:( —F <br /> Date Service Completed (if already completed): SERVICE CODE: P II E: <br /> Fee Amount: [s Amount Paid [ S2— Payment Date v <br /> Payment Type L Invoice# 6Neck# 2 $� $2 Receive By: <br /> ti <br /> EHD'48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />