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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # SERVICE REQUEST # <br /> Fuel Station I' AbDO .) J :j -2 S ` P�W (8- (ol <br /> OWNER / OPERATOR <br /> Harpreet Singh CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> Gavinko Gas & Food <br /> SITE ADDRESS 7700 Moreland St Stockton <br /> Street Number Direction I Street Name Citv Zip Code <br /> HOME or MAILING ADDRESS ( If Different from Site Address ) <br /> Street Number Street Name <br /> CIN STATE ZIP <br /> PHONE # 1 ExT • APN # LAND USE APPLICATION # <br /> ( 925 ) 579 -4865 <br /> PHONE #2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> Margaret Smith for BZ Maintenance CHECK if BILLING ADDRESc <br /> BUSINESS NAME PHONE # ExT . <br /> BZ Maintenance 916 371 - 2380 <br /> HOME or MAILING ADDRESS FAX # <br /> PO Box 933 ( ) <br /> CITY W Sacramento STATE CA ZIP 95691 <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 , Standar TATE DERAL IawS . <br /> APPLICANT ' S SIGNATURE : SmiDATE : M22 <br /> J <br /> � <br /> ROPERTY / BUSINESS OWNER ❑ OR 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 , 1 , 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 ffFNT <br /> my representative . IVED <br /> TYPE OF SERVICE REQUESTED : SEP 1 2023 <br /> COMMENTS : <br /> SRN JOC, DIIIN COUNTY <br /> Remove current dispensers . Install ( 3 ) Gilbarco 700 3 + 0 dispensers and ( 1 ) Gilbarco 700 3 + 1 dispenser ,wWH1DEPI" I NTAL <br /> WENT <br /> Bravo conversion frames and deflector kits . Upgrade Veeder Root software . Change from Assist to Balance . <br /> Install new Balance hanging hardware . Test functionality upon completion . <br /> ACCEPTED BY : SLA <br /> rC 1\ / La EMPLOYEE # : DATE : <br /> Vl i z 3 <br /> ASSIGNED TO : vu o Aparew, i EMPLOYEE # : DATE : <br /> Date Service Completed ( if already completed ) : _ — SERVICE CODE : 2 c] g P IE : 3 0 <br /> Fee Amount : Amount Paid Payment Date <br /> Payment Type Invoice # Check # 3 S Received By : <br /> EHD 48 - 02 - 025 SR FORM ( Golden Rod ) <br /> 07/ 17/08 <br />