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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />UNDERGROIP STORAGE TANK PROGRAM F& WORKSHEET <br />FACILITY ARME <br />FMLITY CONTACT NAME <br />HOLLY SU6Y9R -/6a SWeI EZS SUGAR <br />5svc- &AINKM 557-655-f6t Y20 <br />FACILITY ADDRESS <br />SITE PHONE # WITH AREA CODE <br />5oD HaLLY R IVE <br />835- 32/o <br />CITY <br />STATE <br />ZIP CODE <br /># OF TANKS' <br />AT SITE <br />d , <br />TR/IG1/ <br />CA I <br />g <br />L7dC(/ <br />) <br />APPLICANT BILLING NAME <br />APPLICANT CONTACT NAME <br />HOLLY SU&AR <br />s'125vC 90Aftk&A <br />APPLICANT MAILING ADDRESS <br />APPLICANT PHONE # WITH AREA CODE <br />P. o Qax 60 <br />.559 655'-1761, x2-07 <br />CITY <br />STA�ITE <br />ZIP <br />CODE <br />CIRCLE WORK TO BE DONE: <br />OERInstallation Repair Retrofit <br />TkAGY <br />(,�� <br />q,5-3-78 <br />OFFICE USE ONLY <br />SERVICE REQUEST # FACILITY ID AMOUNT RECEIVED CHECK # RECEIVED BY DATE RECEIVED <br />SIR <br />EH 23 032 (REVISED 8117102) <br />