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g 405241 P.2 PAar 29 12 11:04a LHB Associate's SAN JOAQUIN COUNTY FZWIRONM NT.AL HEALTH DEPARTMENT SERVICE REQUEST FACILCiY ID # SERVICE REQUEST # Type of Business or Property l 2 - GAS to S R �' �' i`' h t STO GAS STATION & CONVENIENCE Otiyry>rR / OAERATOR a CFteGK If 8a�nla AooaEssYJ KIMBEliLY M,I.LLS c/o LOVES COU, p STORES OF CALIFORNIA FACIUTY MMIET p 2?.3 SITEADaREss COLONY ROAD RIPON �9536�36 streetN eci ssreetNuotnx etlo HOWE or MAILING ADDRESS of Dlflerent from Site Address' 10601 N. PEAiNSYLVANIA AVOIiE —et Numter t N CITY OKLAHOMA CITY OK STATE 73120 � PHONE #1 Pxr. APN t1 LANs USE APPLICATION # ( 405 ) 587-1.060 245-340-24 PHOREN EXTi3osDISTRICT LCCATIONCODE j' d-% tri[) A !"rn1D i RF.RVTrF. REOUESTOR BILLING ACKN'OWLEDGEMEN'T: r, the undersigned property or business owner, operator or authorized agent of same, acirnowledge that all site and/or project specific ENyIRoNmEN-rAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to we or my business as identified on this form. I also certify that I have prepared this application and that the work to be performed will be done in accordance with all SA -N Io.AQUmq COUNTY Ordinance Codes, Standard STATE and FEDERAL lases. APPLICANT'S SIGNATURE: DATE: - -OAtr iF PROrERTF I BUSINESS OtNt1 m 130PERATOR/ MA" TAGER Q OTHER UTHA ORTzED cr IfA-PLICAiVT is not tile&a'FLVGPrIR7i proof ofaufhorizadon In sign is required Title AUTHORIZATTON TO RELEASE INFORMATION: 'When applicable, I, the owner or operator of &-a property located at the above site flddress, hereby authorize the release of any and all results, geotechnical data aid/or enviroimnental/site assess=mt information to the SAN JOAQtIIN COUNTY ENVIRONMENTAL HEALTH DEPARTME, lT as soon as it is available and at the same time 41 is provided to me or my representative. TYPE OF SERVICE REautESTED: t,t S`r ,E�� ti F coraent:xrs: AR ,� 9 Zp12 NEIL -TM E�'*' ACCEPTEDBY: OLi J£t;�',¢ EMPLOYEE#: �i3 Lt DATE::3 h -0 2 - ASSIGNED ASSIGNED TO: A' 4 i Q t -t EMPLDYEE#: 2(� 7t7 DATE: 3 LIZ Z Date Service Completed (if already compteteo SERMECOOE: (moi PIE: 2 3 c)Y Foo Amount -7 s or -L) Amount Paid �3`�S D -0 Payment Date 3 4 (� Z Payment Type invoice #. Check # C) Ll g� Received By: EHE) 48-02.025 SR FORM (Golden Rod) REVISED 11/1712003 11111111 REQUESTOR_KE CARRUTH CmEcxifBilLmA222=❑ RiCKES ausiNess NAME 624-1985 CONSTRUCTION91b HOME Of MAILING ADDRESS FAX# 4470 YANKEE RILL ROAD SUITE 200 (916) 625-0911 CITY ROCKLIN STATE CA zip 95677 BILLING ACKN'OWLEDGEMEN'T: r, the undersigned property or business owner, operator or authorized agent of same, acirnowledge that all site and/or project specific ENyIRoNmEN-rAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to we or my business as identified on this form. I also certify that I have prepared this application and that the work to be performed will be done in accordance with all SA -N Io.AQUmq COUNTY Ordinance Codes, Standard STATE and FEDERAL lases. APPLICANT'S SIGNATURE: DATE: - -OAtr iF PROrERTF I BUSINESS OtNt1 m 130PERATOR/ MA" TAGER Q OTHER UTHA ORTzED cr IfA-PLICAiVT is not tile&a'FLVGPrIR7i proof ofaufhorizadon In sign is required Title AUTHORIZATTON TO RELEASE INFORMATION: 'When applicable, I, the owner or operator of &-a property located at the above site flddress, hereby authorize the release of any and all results, geotechnical data aid/or enviroimnental/site assess=mt information to the SAN JOAQtIIN COUNTY ENVIRONMENTAL HEALTH DEPARTME, lT as soon as it is available and at the same time 41 is provided to me or my representative. TYPE OF SERVICE REautESTED: t,t S`r ,E�� ti F coraent:xrs: AR ,� 9 Zp12 NEIL -TM E�'*' ACCEPTEDBY: OLi J£t;�',¢ EMPLOYEE#: �i3 Lt DATE::3 h -0 2 - ASSIGNED ASSIGNED TO: A' 4 i Q t -t EMPLDYEE#: 2(� 7t7 DATE: 3 LIZ Z Date Service Completed (if already compteteo SERMECOOE: (moi PIE: 2 3 c)Y Foo Amount -7 s or -L) Amount Paid �3`�S D -0 Payment Date 3 4 (� Z Payment Type invoice #. Check # C) Ll g� Received By: EHE) 48-02.025 SR FORM (Golden Rod) REVISED 11/1712003 11111111