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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID #r ' SERVICE REQUEST # <br /> Gas Station and convenience store � � _7 �j � V g 5 3 <br /> OWNER / OPERATOR <br /> CHECK If BILLING ADDRESS <br /> Ali Hussaini <br /> FACILITY NAME <br /> A&A Gas & Food Mart <br /> SITE ADDRESS <br /> 16 E Harding Way Stockton 95204 <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, API # LAND USE APPLICATION # <br /> ( 2094466 -9516 <br /> PHONE #2 EXT, BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> ECO -CHEK Compliance , Inc . <br /> BUSINESS NAME PHONE # EXT. <br /> 925 99-6294 <br /> HOME or MAILING ADDRESS FAx # <br /> P . O . Box 1394 ( ) <br /> CITY Lafayette STATE CA ZIP 94549 <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 FEDER <br /> APPLICANT ' S SIGNATURE : - DATE : 03/07/2024 <br /> PROPERTY / BUSINESS OWNER ❑ OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT j3 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 <br /> site address , hereby authorize the release of any and all results , geotechnical data and/or environmental/site assessm nt information <br /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the same time It Is prtp me Or <br /> my representative . rM <br /> TYPE OF SERVICE REQUESTED : <br /> COMMENTS : <br /> C, c s� Joq 120?y <br /> NFq Ty oQ q 4^/ oU� TY <br /> RTM�� T <br /> ACCEPTED BY : C �aA/A EMPLOYEE # : DATE : ' 3 � <br /> ASSIGNED TO : G EMPLOYEE # : DATE: I �/ <br /> Date Service Completed ( if already completed ) : SERVICE CODE : gqf -2414 PIE : 2? 1 �1 <br /> Fee Amount: _ f Cz Amount Pai 8 � Payment Date <br /> Payment Type Invoice # Check # 77771/2149 � Received By : <br /> EHD 48-02-025 SR FORM (Golden Rod) <br /> 07/ 17/08 <br />