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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property Q FACILITY ID # f�SERVICE REQUEST # <br /> OWNER / OPERATOR <br /> Speedway LLC CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> Speedway 4612 <br /> SITE ADDRESS 2448 w Lodi F96Z5242 <br /> Kettleman Lane <br /> Street Number Direction Street Name Cit i 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 /> ( ) <br /> PHONE #2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR Erb` <br /> HECK If BILLING ADDRE0 & C&1! qr'd A <br /> SS <br /> BUSINESS NAMEHONE EXT, <br /> Serv) C_ e fibr1 f S �rJs . <I : Z/ L/ 5 <br /> HOME or MAILING ADDRESS �" FAX # <br /> co LU ir1 if ✓,Q wo'� ( ) <br /> CITY (S,aP7 ' STATE ZIP qj <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 , STAT and FEDERAL laws . <br /> APPLICANT 'S SIGNATURE : DATE : 5 /30/2023 <br /> PROPERTY I BUSINESS OWNER ❑ OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT Contractor <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 time It IS prAiy�gdtp_me or <br /> my representative . /H� ]l /M� E o- <br /> TYPE OF SERVICE REQUESTED : <br /> COMMENTS : JUN 0 7 202 <br /> SAN JOAQUIN C <br /> HEALTIRONMENTATY <br /> H D, TA <br /> T <br /> ACCEPTED BY : s EMPLOYEE # : DATE: <br /> ASSIGNED TO : V <br /> ; tVan I v `�' / I Ila 6(/l� / EMPLOYEE # : DATE: <br /> Date Service Completed ( Wa4eady comple ) : ! SERVICE CODE : 147f� ill C P 1 E : 210? <br /> Fee Amount: �LT � Amount Pai �' 6D Payment Date '017 I)L3 <br /> Payment Type v ' Invoice # Check # 1 bZ ! Z / s� `7 Received By : <br /> EHD 48-02-025 SR FORM (Golden Rod) <br /> 07/ 17/08 <br />