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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # SERVICE REQUEST # <br /> OWNER / OPERATOR Five G Arch , LLC . C/O Jivtesh Gill <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME Arch Road Travel Plaza <br /> SITEADDRESS 4850 S E Frontage Rd Stockton 95215 <br /> Street Number Direction I Street Name City Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 3142 Metro Dr <br /> Street Number Street Name <br /> CITY Stockton STATE CA ZIP 92125 <br /> PHONE #1 ExT. APN # LAND USE APPLICATION # <br /> ( 209 ) 491 -7445 179-48-005 , 006 , 008 , 009 , 010 , 011 <br /> PHONE #2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR James Otto <br /> CHECK If BILLING ADDRESS <br /> ,% <br /> BUSINESS NAME LC Services PHONE # EXT. <br /> HOME or MAILING ADDRESS 3887 N Valentine Ave FAx # <br /> CITY Fresno STATE CA ZIP 93722 <br /> ENT <br /> BILLING ACKNOWLEDGEMENT: I , the undersigned property or business owner, operator or authorized agent oREWfeIVED <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 . ') P 2 2 2022 <br /> also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN ,4QNWINC0UNTY <br /> COUNTY Ordinance Codes, Standards , STATE and FEDERAL laws . GwIRONNIENTAL <br /> HEALTH DEPAR[ MENI <br /> APPLICANT ' S SIGNATURE : �JamesOtto DATE : 9/9/2022 <br /> PROPERTY / BUSINESS OWNER ❑ OPERATOR I MANAGER ❑ OTHER AUTHORIZED AGENT ® Project Coordinator <br /> If APPLICANT IS not the BILLING PARTY, /hoof 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 provided t0 me Or <br /> my representative . <br /> TYPE OF SERVICE REQUESTED : C� . F Al,",(,) �� S <br /> COMMENTS: <br /> ACCEPTED BY: \\ 1' j e I\ , /� � EMPLOYEE #: DATE: ZZ <br /> ASSIGNED TO : ILOo EMPLOYEE #: DATE: <br /> Date Service Completed ( if already completed ) : _-- SERVICE CODE :/ _ y PIE: 3 Q � <br /> Fee Amount: 3 � 2 (� Amount Paid l — P yment Date 'I 4.,) <br /> Payment Type Invoice # Check # J Received By : <br /> EHD 48-02-025 SR FORM (Golden Rod) <br /> 07/17/08 <br />