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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business <br />or Property <br />C <br />Ff} <br />FACILITY ID # <br />o'o 17 <br />( <br />SERVICE REQUEST # <br />q <br />OWNER / OPERATOR CaGasoline Express <br />S,q N � 20 <br />CHECK If BILLING ADDRESS❑ <br />FACILITY NAME <br />A Gas - Food Mart <br />R0 C 774 A <br />SITE ADDRESS <br />2115 <br />Street Number <br />W <br />Direction <br />Yosemite <br />Street Name <br />M <br />Manteca <br />City <br />95337 <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site <br />Address) <br />Street <br />Number <br />#: <br />Street Name <br />CITY <br />Date Service Completed (if already completed): <br />SERVICE CODE: �� /�G�S <br />STATE ZIP <br />PHONE #1 <br />( ) <br />Exr. <br />466 o <br />APN # <br />Payment Date ' ( Z3 <br />LAND USE APPLICATION # <br />PHONE #2 <br />ExT• <br />Check # <br />U2j�`� 3(P Received By: <br />8OS DISTRICT <br />LOCATION CODE <br />CONTRACTOR /SERVICE REQUESTOR <br />�= <br />_ w- <br />40 971-2445 <br />.. e - <br />BILLING ACKNOWLEDGEMENT: I, the undersigned property <br />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, STATE and FEDERAL laws. <br />APPLICANT'S SIGNATURE: 10 9 <br />DATE: 6/19/2023 <br />PROPERTY /BUSINESS OWNER ❑ OPERATOR/ MANAGER <br />❑ OTHER AUTHORIZED AGENT ® Contractor <br />If APPLICANT /s nor rhe BILLING PARTY, proof of aultiormauon to Sigh is regUlref/ 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 />t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is provided to me or <br />my reoresentative. PA X.. _ Cp <br />TYPE OF SERVICE REQUESTED: <br />C <br />COMMENTS: <br />JUN <br />� <br />S,q N � 20 <br />�/0(gf <br />HEALTy /4 <br />R0 C 774 A <br />r M <br />ACCEPTED BY: <br />CIA <br />EMPLOYEE <br />M <br />DATE:0 I 1 <br />/ <br />ASSIGNED TO: ( <br />EMPLOYEE <br />#: <br />DATE: I <br />27J <br />Date Service Completed (if already completed): <br />SERVICE CODE: �� /�G�S <br />PIE:. 5l J0 <br />Fee Amount: L� ,f7 `' <br />Amount Pa <br />466 o <br />Payment Date ' ( Z3 <br />Payment Type � <br />Invoice # <br />Check # <br />U2j�`� 3(P Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />o�lvroa <br />