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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # SERVICE REQUEST # <br /> Gas Station 1� ' 5 R 00 7 7 5 <br /> OWNER I OPERATOR <br /> Harpreet Singh CHECK if BILLING ADDRESS <br /> FACILITY NAME <br /> Tracy Market <br /> SITE ADDRESS E <br /> 15 Grant Line Rd , Tracy 95376 <br /> Street Number Direction Street Name Cit Zi code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE #1 EXT . APN # LAND USE APPLICATION # <br /> ( ) <br /> PHONE #2 ExT . EMAIL BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE # EXT. <br /> ECO -CHEK Compliance , Inc . ( 925 ) 499-6294 <br /> HOME or MAILING ADDRESS FAX # <br /> P . O . Box 1394 ( ) <br /> CITY STATE zip EMAIL <br /> Lafa ette CA 94549 permits@eco-chek . com <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 activity <br /> 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 FEDER <br /> APPLICANT ' S SIGNATURE : _ DATE : 02/07/2024 <br /> PROPERTY / BUSINESS OWNER ❑ OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT [2[Compliance Operations Associate <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 site <br /> address , hereby authorize the release of any and all results , geotechnical data and/or environmental/site assessment information bole <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the same time It Is provided t0 mkJ <br /> representative . F�T <br /> TYPE OF SERVICE REQUESTED : <br /> COMMENTS: S <br /> ,JOq ? o?y <br /> E44 ti�AVAt C LINTY <br /> RT < <br /> FNT <br /> ACCEPTED BY: �1 �1 I� /1 4�i] EMPLOYEE # : DATE : 2/ / 15 24 <br /> ASSIGNED TO : 5 L/ via 0 LGI C�n!/lt EMPLOYEE # : DATE: 2 / tJ <br /> Date Service Completed ( if already completed ) : !/ / ' 2 SERVICE CODE : �� � 2 PIE : 230 f(l <br /> Fee Amount: �/� Amount Paid ! `� -�- Z �v Payment Date 022 L <br /> Payment Type w '4 � ' Invoice # ( 'Check # / '7 ( ISDIS Receive By : <br /> F. IILire � t) ktai I ii 1 ' l7 � sz7zg7 <br /> EHD 48-02-025 ^ „ 0 _ n �� �j SR FORM (Golden Rod) <br /> 03/22/23 Y*G (� U <br />