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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 stationb <br /> OWNER / OPERATOR <br /> Reliance Gas Investments - Jivtesh Gill CHECKifBILLING ADDRESS <br /> FACILITY NAME Tracy 76 <br /> SITE ADDRESS 2420 W Grant Line Tracy 95377 <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 CHECK if BILLING ADDRESS <br /> BUSINESS NAME LC Services PHONE # ExT, <br /> 55 444- 1730 <br /> HOME or MAILING ADDRESS FAX # <br /> 3887 N Valentine Ave ( ) <br /> c 'TM 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 O l o 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 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 IS provided to me Or <br /> my representative . <br /> TYPE OF SERVICE REQUESTED : (� SJ <br /> COMMENTS : �, VC <br /> 6 <br /> MgR3f !� <br /> ?OZ2 <br /> SAN ,/OAQL, <br /> HEgLTH D A, CO UNTy <br /> ACCEPTED BY: /���� EMPLOYEE #: DATE: �1T Z2 <br /> ASSIGNED TO : /) J�77 , EMPLOYEE #: DATE: <br /> Date Service Complevvte/d� ( if already completed) : SERVICE CODE : �9 g �2e? 4 PIE : 2 � 0 <br /> Fee Amount: 4rz/ O Amount Pai 1 ` Payment Date / Z Z <br /> Payment Type Invoice # Check # 267 ' Received By : <br /> EHD 48-02-025 SR FORM (Golden Rod) <br /> 07/17/08 <br />