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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # SERVICE REQUEST # <br /> Retail Gasoline Facility a- +844 93 fAWN K uC3 t Cl V <br /> OWNER / OPERATOR Mushtaq Omar <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME SB Gas and Market <br /> SITE ADDRESS 515 S W 11 th St Tracy 95376 <br /> Street Number Direction Street Name CityZin Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) Same <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 Mushtaq Omar <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME Tank Tight systems, Inc. PHONE# <br /> ONE# 432-5211 EXT. <br /> HOME or MAILING ADDRESS FAX# <br /> 515W11thSt ( ) <br /> CITY Tracy STATE CA ZIP 9376 <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, STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: — DATE: 07/14/2023 <br /> PROPERTY I BUSINESS OWNER ® OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <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 /> t0 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 /> PAY MEN 1 <br /> TYPE OF SERVICE REQUESTED: 61/J 7— /�� RECEIVED <br /> COMMENTS: bf)"Q � ` (��2 <br /> f� / �t'/ U L� JUL 17 2023 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: r �+�J/ �� � �� EMPLOYEE#: DATE: -7 141g , <br /> ASSIGNED TO: v/ lam- _ f 1 EMPLOYEE#: DATE: 711 y Z3✓ <br /> Date Service Completed (if already completed): SERVICE CODE: �,2 9 �> PIE: 50O <br /> Fee Amount: .f Gf F&7 Amount Paid Payment Date �� <br /> Payment Type Invoice # C c # S l Received By:W—Z <br /> 7b <br /> EHD 48-02-025 Q l%e� SR FORM (Golden Rod) <br /> 07/17/08 <br />