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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID# SERVICE REQUEST# CONVENIENCE/GAS STATION/LAUNDROMAT A ,4 I WU /-q s✓/ �, L��, f OWNER/OPERATOR W, NAJIBUL SIDDIQI CHECK if BILLING ADDRESS FAcll NAME CALIFORNIA TRACY CONNECT INC(CENTRAL GAS) SITE ADDRESS 610 s Street Number Direction CHEROKEE LN LORI CA 95249 HOME Or MAILING ADDRESS (If Different from Site Address) Street Number Street Name CITY STATE zip PHONE#1 E'T. ( 951 )691- APN# LAND USE APPLICATION# 0501 PHONE#Z EXT. ( ) BOS DISTRICT LOCATION CODE CONTRACTOR/ SERVICE REQUESTOR REQUESTOR CHECK If BILLING ADDRESS BUSINESS NAME PHONE# Err. HOME or MAILING ADDRESS FAX# CITY STATE LP BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be baled to me or my business as identified on this form. 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 COUNTY Ordinance Codes,Standards,STATE and FEDERAL laws. APPLICANT'S SIGNATURE: N.SEDDIQI DATE: 01/27/2022 PROPERTY/BUSINESS OWNER©OPERATOR/MANAGER©OTHER AUTHORIZED AGENT IfAPPLICANT IS not the BILLING PAR TP proof of authorization to sign is required Title AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. TYPE OF SERVICE REQUESTED: HEALTH PERMIT INSPECTION ozd � 2� X03