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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 Gas Station 06 �7 q� � 0S , � <br /> 008 � D [15 <br /> OWNER / OPERATOR <br /> Ravinder Singh CHECK If BILLINGADDRESSE] <br /> FACILITY NAME <br /> West Ln Chevron <br /> SITE ADDRESS <br /> Stockton 95210 <br /> 4747 Street Number Direction West Ln Street Name City Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Same as above . Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE #1 EXT, APN # LAND USE APPLICATION # <br /> ( 209) 992 - 1735 10437010 <br /> PHONE #2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> James Otto CHECK If BILLING ADDRESSIZ <br /> BUSINESS NAME LC Services PHONE # EXT, <br /> 559 444- 1730 <br /> HOME or MAILING ADDRESS 3887 N Valentine Ave FAx # <br /> ( ) <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 allproject 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 : LWIU06 DATE : 7/8/2021 <br /> PROPERTY / BUSINESS OWNER ❑ O RATOR / 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 /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as Soon as It Is available and at the same tlmefl}i6�(OV'd d to me or <br /> my representative . rr �YMME <br /> TYPE OF SERVICE REQUESTED : S � -Z 7b1 ? rNck; tI VEiD <br /> COMMENTS : AUG 02 2021 <br /> SAN JOAQUIN COUNTY <br /> LDEATHEATHRMENT <br /> ACCEPTED BY : -� ^ \ i /I EMPLOYEE # : DATE: 7/; <br /> ASSIGNED TO : �v /� n `( 1,1 I /UY� �� ��i EMPLOYEE # : DATE : `�ua .f <br /> Date Service Completed ( if already completed) : SERVICE CODE : / _ /�/ PIE : <br /> Fee Amount : 30Tl�) Amount Pa`iD w Payment Date <br /> Payment Type Invoice # Check # F6 Recei ed By : <br /> EHD 48-02-025 SR FORM (Golden Rod) <br /> 07/17/08 <br />