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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 with Convenience Store F 1Qa <br /> OWNER/OPERATOR <br /> AB March Ln Stockton Operating Inc CHECK if BILLING ADDRESS <br /> FACILITY NAME <br /> 76 Gas Station <br /> SITE ADDRESS EMarch Ln Stockton 95210 <br /> 1916 Street Number Direction Street Name city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 3633 Inland Empire Blvd Suite 500 <br /> 3633 Street Number Street Name <br /> CITY STATE ZIP <br /> Ontario Ca 91764 <br /> PHONE#1 EXT• APN# LAND USE APPLICATION# <br /> (909 ) 515-8093 096-030-29 <br /> PHONE#2 EXT• BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> Michelle Magallon CHECK It BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT• <br /> AB March Ln Stockton Operating Inc 909 515-8093 <br /> HOME or MAILING ADDRESS FAx# <br /> 3633 Inland Empire Blvd Suite 500 ( ) <br /> CITY Ontario STATE Ca ZIP <br /> 91764 <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 <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: ��fL DATE. 12/15/2022 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT it Executive Assistant <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 <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 JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available andat�lthe same time it is <br /> provided to me or my representative. A ye <br /> TYPE OF SERVICE REQUESTED:Site Visit for Transfer of Ownership CES <br /> COMMENTS: DEC <br /> Food Facility Permit requested by buyers purchasing gas station and C-Store Sq ZO?? <br /> N✓Oq <br /> ENV/ QUINCO <br /> HEgLTry pEpgRT74L Ty <br /> E 7- <br /> ACCEPTED BY--eD J+ EMPLOYEEMqW- S DATE: 12•/ r /-z-'7— <br /> ASSIGNED TO: EMPLOYEE M ZS DATE. /Z Q G <br /> Date Service Completed (if already completed): SERVICE CODE: Q6 PIE: I6O e2 <br /> Fee Amount: $ 5 Amount Paid / Payment Date Z� <br /> Payment Type Invoice# Check# JS /u_S Re eive By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 �I9 a <br />