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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # SERVICE REQUEST # <br /> Retail Fueling Station Pvo00F07?0J SI. 006O & <br /> OWNER If OPERATOR <br /> EAGE Investments - Jivtesh Gill CHECKIfBILLING ADDRESSE] <br /> FACILITY NAME Arch ARCO <br /> SITEADDRESS 4855S State Route 99 Stockton 95215 <br /> Street Number Direction 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 #1 EXT. APN # LAND USE APPLICATION # <br /> (209) 948 -2438 <br /> PHONE #2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR James Otto <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME LC Services PHONE # EXT. <br /> (559 ) 444 - 1730 <br /> HOME or MAILING ADDRESS 3887 N Valentine Ave FAx # <br /> CITY Fresno STATE CA ZIP 93722 <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 /> 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 : James Otto DATE : 3/2/2022 <br /> PROPERTY / BUSINESS OWNER ❑ OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT ® Project Coordinator <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 environ ental/site assessment information <br /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at I it is provided to me or <br /> my representative . �l // ��yV//IP, <br /> Wv <br /> TYPE OF SERVICE REQUESTED : �� �� v A <br /> COMMENTS : S A ,/Oq Q 3 2022 <br /> HEATH pE TO ANT Y <br /> MENT <br /> ACCEPTED BY: tae EMPLOYEE #: DATE : <br /> ASSIGNED TO : r . (✓T� l EMPLOYEE #: DATE : Z� <br /> Date Service Completed f already completed) : SERVICE CODE : ,7k,�0 P / E : Z,W0 <br /> Fee Amount : �' it Amount Paid SCS: (� Payment Date <br /> '311 <br /> Payment Type Invoice # Check # 1 eceived By : <br /> EHD 48-02-025 SR FORM (Golden Rod) <br /> 07/17/08 <br />