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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # SERVICE REQUEST # <br /> Gas station 1 y S (�� ( e; C <br /> OWNER / OPERATOR <br /> AakaSh Patel CHECK if BILLING ADDRESS <br /> Kesar Petroleum <br /> SITE ADDRESS 717 W 8th St Stockton 95206 <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 /> ( 408 ) 329-8089 <br /> PHONE #2 EXT, BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR Kurt Ramont <br /> CHECK If BILLING ADDRESS 9 <br /> BUSINESS NAMEPHONE # EXT• <br /> iec services <br /> ) 916-993-6312 <br /> HOME or MAILING ADDRESS FAX # <br /> 4901 Warehouse Way ( ) <br /> CITY Sacramento STATE CA ZIP 95826 <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 <br /> or 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 : / 1Gfi2 /CH.� DATES 03/03/2023 <br /> PROPERTY / BUSINESS OWNER ❑ OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT Fueling coordinator - IEC services <br /> If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required t MENT <br /> AUTHORIZATION TO RELEASE INFORMATION : When applicable, I, the owner or operator of the prRoperfy IooRed at the <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or enviro*Rats3e 201asment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative . SAN JOAQUI <br /> NODUNTY <br /> IRONTAL <br /> TYPE OF SERVICE REQUESTED : Vl S � I <br /> COMMENTS: <br /> FULL SOW ATTACHED <br /> i C_ on v <br /> - AA t <br /> ACCEPTED BY: \ ! EMPLOYEE #: DATE : <br /> ASSIGNED TO : d ' �s EMPLOYEE #: DATE :la 4 r �j ✓�!Ja <br /> Date Service Completed ( If already completed) : ( SERVICE CODE : 1 2, CltJ P 1 E :� 3 <br /> Fee Amount: z/&) Amount Paid Payment Date <br /> Payment Type ' V ` S j�— Invoice # CJiecit # 5 g Received By: <br /> EHD 48-02-025 — - — - 3 ( a - SR FORM (Golden Rod ) <br /> REVISED 11 /17/2003 f !) rj � tj 5 313 Xv2, <br />