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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID # ERVI Convenience Store ^` CITY STATE ZIP HLS S`O)SVE OWNER / OPERATOR Ross Hillesheim CHECK IfBILLING ADDRE33o FACILITY NAME Charter Way Holdings, LLC SITE ADDRESS 1720 S I Fresno Avenue NEgLTH pEpgR �T Stockton 95206 I Street Number D Slroot Namo EMPLOYEE#: 6213 DATE: 11_2-21 Zip C.de HOME or MAILING ADDRESS (If Different from Site Address) 300 Frank H Ogawa Plaza Suite#340 Street Number Street Name CITY Oakland STATE CA ZIP 94612 PHONE#1 EA'r. APN# Fee Amount: 684 LANDi1S AP LICATI N# 1 831 1392-6424 163-820-680 & 690 Lan�dEeve�opmen7 permit approved by the city Invoice # Check # /3 9 9Z of Stockton. PHONE #2 En. BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR SAME AS ABOVE CHECK 1 f BILLING ADDRESS BUSINESS NAME PHONE # EXT. HOME or MAILING ADDRESS FAX# CITY STATE ZIP BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project specific ENVIRON ME TAL HEA DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as identified o this form. I also certify that I have prepared this ap li ation and thagth , orkj� be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, Standards, S A and FFLERA Is s. / APPLICANT'S SIGNATURE: DATE: `, t�j6 V -Z4 2 1 PROPERTY/ BUSINESS OWNER® OPERATOR I MANAGER'S OTHER AUTHORIZED AGENT❑ /f APPLICANT is not the BILLING PARTY proof ojaailrarization to sign is required Title AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, 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 CotJNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the some time it is provided to me or my representative. P TYPE OF SERVICE REQUESTED: Hol & Prepared foods EC COMMENTS: L. N� Typical/ Industry standard convenience store. V0 2 ?021 SAN JOAQUI NEgLTH pEpgR �T ACCEPTED BY: Vidal Pedraza EMPLOYEE#: 6213 DATE: 11_2-21 ASSIGNED TO: EMPLOYEE#: 3361 DATE: 11-2-21 Date Service Completed (if already completed): SERVICE CODE: 523 P IE: 1601 Fee Amount: 684 Amount Pai 68 • oa Payment Date Payment Type tom_ Invoice # Check # /3 9 9Z 1 Received By: EHD 48-02-025 REVISED 11/17/2003 h',11 0\ SR FORM (Golden Rod)