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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID # SERVICE REQUEST # Fuel Station �j Z S9�Q% D $=il (o=1 OWNER / OPERATOR Harpreet Singh CHECK If BILLING ADDRESS FACILITY NAME Gavinko Gas & Food SITE ADDRESS 7700 Moreland St Stockton Street Number Direction I Street Name Cit Zi Code HOME or MAILING ADDRESS (If Different from Site Address) Street Number Street Name CITY STATE ZIP PHONE #t EXT. APN # LAND USE APPLICATION # ( 925 ) 579-4865 PHONE #2 EXT, BOS DISTRICT LOCATION CODE ( ) CONTRACTOR / SERVICE REQUESTOR REQUESTOR Margaret Smith for BZ Maintenance CHECK If BILLING ADDRES BUSINESS NAME PHONE # EXT. BZ Maintenance 916 371 -2380 HOME or MAILING ADDRESS FAX # PO Box 933 ( ) CITY W Sacramento STATE CA ZIP 95691 BILLING ACKNOWLEDGEMENT : I , the undersigned property or business owner, operator or authorized agent of same , acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project Or activity will be billed to me or my business as identified on this form . also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, Standar s, TATE DERAL laws. Q APPLICANT' S SIGNATURE : DATE : APPLICANT' S / BUSINESS OWNER ❑ OR / MANAGER ❑ OTHER AUTHORIZED AGENT ❑ If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required Title AUTHORIZATION TO RELEASE INFORMATION : When applicable , I , 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 COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the Same time It IS providedFENT my representative . IVED TYPE OF SERVICE REQUESTED : S i( 7�4 t SEP 1 2023 COMMENTS : SAN JOAQUIN COUNTY Remove current dispensers . Install (3) Gilbarco 700 3 + 0 dispensers and ( 1 ) Gilbarco 700 3 + 1 dispenser ,)(!1WDEP RTMeNT Bravo conversion frames and deflector kits . Upgrade Veeder Root software . Change from Assist to Balance . Install new Balance hanging hardware . Test functionality upon completion . ACCEPTED BY: I -1 rl�f Je�a EMPLOYEE #: DATE : / ,f )I � 3 ASSIGNED TO : IV L �0 0 l I (W r EMPLOYEE #: DATE : Z' Date Service Completed (if already completed) : _ SERVICE CODE : 2 9 U PIE : p �' Fee Amount: � y O (f at, Amount Paid Payment Date o � ( )ib Payment Type2 Invoice # Check # Received By : EHD 48-02-025 SR FORM (Golden Rod) 07/ 17/08