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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property_ FACILITY ID # SERVICE REQUEST # <br /> G a,/,3 ISJoil bYl F/- ovb '532 S" <br /> OWNER / OPERATOR <br /> Ashish Boveja CHECK If BILLING ADDRESS <br /> FACILITY NAME Food Mart Gas <br /> SITE ADDRESS 2185 E Fremont Street Stockton 95212 <br /> Street Number DI ectIon 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 /> ( ) 408 -204 - 1636 SII <br /> PHONE #2 ExT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR Afforda Test <br /> CHECK If BILLING ADDRESS 13 <br /> BUSINESS NAME Afforda Test PHONE # 209 -744 -0112 ExT. <br /> HOME or MAILING ADDRESS 41 CV Street 2nd FAX # G <br /> �7 l ( ) <br /> CITY Galt STATE CA ZIP 95632 <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 and FEDERAL laws . <br /> APPLICANT'S SIGNATURE : tA ! q DATE : <br /> PROPERTY I BUSINESS OWNER Efo� OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT IS not the BILLING PARTY, proof Of authorization f0 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 /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it IVided to me or <br /> my representative . *cc <br /> TYPE OF SERVICE REQUESTED : u r gz&v t' C� V <br /> COMMENTS : �J C �( Azaiy <br /> v r � ! <br /> NF N (r/RpowCZOZZ <br /> cryo pM�����r <br /> ACCEPTED BY : , �f n EMPLOYEE #: DATE: 1 r <br /> ASSIGNED TO : V I el ,/7`7e? / '1 t EMPLOYEE #: DATE : <br /> Date Service Completed ( if already completed) : SERVICE CODE : 247F PIE :2009 <br /> Fee Amount : � �' Amount Paid Ts� OD Payment Date 1 D ZZ <br /> Payment Type Invoice # Check # 13 '7 1 3Sr Recelved By: <br /> LAE <br /> EHD 48- 02- 025 SR FORM (Golden Rod ) <br /> 07/17/08 <br />