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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />Gas station / Convenience Store <br />FACILITY ID # <br />3 1 6, 3 <br />SERVICE REQUEST # <br />sRicabgq4 1 <br />OWNER / OPERATOR <br />CHECK if Mike Souza BILLING ADDRESS <br />FACILITY NAME Grab-N-GO <br />SITE ADDRESS 2420 <br />Street Number Direction <br />West Grant Line Road <br />Street Name <br />Tracy <br />City <br />95377 <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Street Number Street Name <br />Orr STATE CA ZIP <br />PHONE #1 Err. <br />( 209 ) 835-8330 <br />APN # <br />2358-600-360 / 237-190-220 <br />LAND USE APPLICATION # <br />PHONE #2 EXT. <br />( ) <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />Stacey Wellnitz CHECK if BILLING ADDRESS El <br />BUSINESS NAME <br />Commercial Arch <br />PHONE # <br />( 209 ) 571-8158 <br />Err. <br />HOME Or MAILING ADDRESS <br />616 14th Street <br />Fax # <br />( ) <br />Cry Modesto STATE CA ZIP 95354 <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 <br />or activity will be billed to me or my business as identified on this form. <br />I 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: <br /> <br />DATE: July 11,2023 <br /> <br />PROPERTY! BUSINESS OWNER <br /> <br />OPERATOR / MANAGER 0 OTHER AUTHORIZED AGENT El <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 <br />above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br />information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br />provided to me or my representative. <br />TYPE OF SERVICE REQUESTED: C - < 37,1e‹ <br /> <br />._ re144--a/G2--K ID f EagItA <br />COMMENTS: JUL 1 2 2 0 2 3 <br />SAN JOAQUIN COUN <br />ENVIRONME Y. <br />NTAL T HEALTH DEPARTMENT <br />ACCEPTED BY: (ci V 71/{ C.-, LA EMPLOYEE #: DATE: 9.--"( Z_5 <br />ASSIGNED TO: tai, li a VC-.5 <br />EMPLOYEE #: DATE: -- ( ( --- -e....- _) <br />Date Service Completed (if already completed): SERVICE CODE: -CI‘; / P/ • 60 / <br />Fee Amount: pa, . 00 Amount Paid fj/ dr• — Payment Date <br />Received By:027" Payment Type Type V 1i--0 pf Invoice # Check # <br />SR FORM (Golden Rod) EHD 48-02-025 <br />REVISED 11/17/2003