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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # SERVICE REQUEST #C <br /> Fuel Station 1) Lp e( 7 <br /> OWNER I OPERATOR <br /> Gurpartap Singh CHECK If BILLING ADDRESS <br /> FACILITY NAME Wilson Chevron <br /> SITE ADDRESS 4343 Wilson Way Stockton 95205 <br /> Street Number Direction Street Name city Zip Code <br /> HOME or MAILING ADDRESS ( If Different from Site Address) P . O . Box 62 <br /> Street Number Street Name <br /> CITY Mountain House STATE CA ZIP 95391 <br /> PHONE #1 ExT• APN # LAND USE APPLICATION # <br /> ( 925) 724-8010 132 -02 -022 <br /> PHONE #2 ExT• SOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> Gurpartap Singh CHECK If BILLING ADDRESSO <br /> BUSINESS NAME Wilson Chevron PHONE # EXT. <br /> 925 724 -8010 <br /> HOME or MAILING ADDRESS P . O . Box 6 FAx # <br /> CITY Mountain House STATE CA ZIP 95391 <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 : aDATE : 5-5-22 <br /> PROPERTY I BUSINESS OWNER ® OPERATOR I 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 asse P formation <br /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it IS available and at the same time it IQUZI <br /> �lAq <br /> my representative. \ C V <br /> TYPE OF SERVICE REQUESTED : I �j I (% / ! JAN f <br /> COMMENTS : t SAN J 23 <br /> U J I °AQIJ, <br /> NEAP ND PMENT, CN7 <br /> MENT <br /> ACCEPTED BY : / EMPLOYEE #: DATE:(AJ <br /> VY <br /> ASSIGNED TO : �1 <3V�,2 EMPLOYEE #: DATE: I � I W INS tz <br /> Date Service Completed (if already completed) : SERVICE CODE: Ig q J1 PIE: 0730 -3 <br /> Fee Amount: I Amount Pai 3 / D Payment Date V12A.3 <br /> Payment Type SGS— Invoice # Check # 1 3 "71oZ R ceiv d By : <br /> EHD 48-02-025 SR FORM (Golden Rod) <br /> 07/17108 <br />