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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Convenience Store ICH 00D q <br /> OWNER/OPERATOR <br /> Lawrence Wight CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> Arco Gas Station Convenience Store <br /> SITES A9DODRRESS W Benjamin Holt Drive Stockton 95207 <br /> Street Number I Direct lon Street Name city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#t EXT. APN# LAND USE APPLICATION# <br /> ( 209 ) 662-4874 097-630-32 <br /> PHONE#2 EXT. BIDS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> Steven Torres, Architect CHECK if BILLING ADDRESS <br /> BUSINESS NAME Apex Architecture PHONE# EXT. <br /> ( 662-4874 <br /> HOME or MAILING ADDRESS FAX# <br /> 735 S. Shasta Ave ( ) <br /> CITY Stockton STATE CA. ZIP 95205 <br /> BILLING ACKNOWLEDGEMENT: 1, 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: . DATE: 5/21/2021 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT® Architect <br /> If APPLICANT is not the BILLING PARTY.Proof Of authorization t0 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 JOAQUrN 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: Prq n G h-e GK <br /> COMMENTS: ^/q 4/711"tq L'' /7O f m a-,l • ��'7 <br /> Plate s <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: M F/Oh r 5 EMPLOYEEM DATE: <br /> Date Service Completed (if already Completed): SERVICE CODE: c5 P I E: W I <br /> Fee Amount• Amount Paid s Payment Date .5—/,2 2 <br /> Payment Type C Invoice# # 8 I Received By: <br /> EHD 48-02-025 SR F Z(Golden Rod) <br /> REVISED 11I/17/2003 <br />