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• <br />SAN JOAQUIN COUNTY ENVQtO;'1iMF.iYI'AL HEALTH j)ErARTwNT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACM rf # <br />LIJ <br />SERVICE REQUEST # <br />ChrrK if BILLwG ADDREss <br />BuSINEss NAfte Alltech Petro Ca <br />CiIWNER I OPERATOR <br />F.T. <br />Costco Wholesale <br />2D <br />CHECK it BILLING ADDRESS 0 <br />FAGu"NAME Costco wholesale Manteca, <br />CA <br />FAR# <br />StTEADDR£SS <br />ilaniel St. <br />{209) <br />MaI7teca <br />� Y <br />2440 <br />Date Service Corn~ (Oak "dpC=w6o m": <br />sER+!mOme q <br />1 oie (J/ <br />c <br />Street Name <br />Arnount Paid <br />ci <br />Zr Gode <br />HOME of MmuNG ADDRESS (if DrSferent from Site Address) <br />rrrolee# <br />Check # <br />Received By: <br />Street Mum6er <br />5twevi Name <br />CITY <br />_ <br />STATE ZIP <br />PHONE #1 EXT. <br />AIPN A <br />LAND USE APPLIGAMON $ <br />PHONE#L EIT. <br />( l <br />SOS DISTRICT Locat7oN C0s3E <br />CONTRACTOR/ SERVICE REQC ESTOR <br />REQUESTOR <br />LIJ <br />Isaac Anderson <br />ChrrK if BILLwG ADDREss <br />BuSINEss NAfte Alltech Petro Ca <br />PHONE# <br />F.T. <br />SAN JOAQUIN COUNTY <br />2D <br />532-7320 <br />HOME or MALING ADDRESS p .O. Box 4208 <br />FAR# <br />HEALTH DEPART41ENT <br />ACCEPTED BY' <br />{209) <br />533-2650 <br />CITY Sonora <br />S�Fxm CA <br />Z)P 9537© <br />BILLING ACIKNOWLEDGEMENT: 1, the undersigned properta• or bwdmss awner, operator or am&orized agent of same, <br />acknowledge that all site anchor project specific ENVIRON4t£AiAL HF-ALTH 1➢ �P_axT!+7F-vT hDur3y charges a_ssocia]W with this pn1joci <br />or activity will be billed to rye or mi basimw as identified on this toms. <br />I also certify that I have prepawd this application and that the work to be pafo mad will be done in aocimhowe with all SAta JOAr3um <br />Cot1NTY OraWwxe Co&w, Smordards, Sr{Tc and EEw3LjL laws_ <br />"PLICATrr'S SIGNATURE: f DAA 08-18-2-11 <br />Pxcirt?ttTtt/ Bum a=ow mm[3 ®PCR#TDR, MA -%AGER © 0rKEX A1-j—HMtzE0AG1,iT ® ServiCe Technician <br />df MPuCAXr iw not the BuuarG Awry. proafef outhorkation to sign is required TW r <br />AUTHORIZATION TO RELEASE II4FORMATIONs When applicable. 1. the o%aer or operator of the propert), located at the <br />above site address, hereby authorize the release of any and all results, gevtr hnical data and /m envirOwnenta1;site assessment <br />information to the SAN JOAQUIN COUNTY FN-VMONME TrAL HEAL7H f"A3tTmt_N7 as soon as it is available and at the same tinge it is <br />provided to Ire or my representative. <br />TYPE oF SeRvtcF REG4IESTED: N/A <br />PAYMENT <br />colwwrs: <br />AUG 2 9 2011 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HEALTH DEPART41ENT <br />ACCEPTED BY' <br />EMPLOYEE : <br />�Lq i <br />AssIGNEDTp; jyj /Ja I <br />EMPLtJYEE #: <br />Date Service Corn~ (Oak "dpC=w6o m": <br />sER+!mOme q <br />1 oie (J/ <br />c <br />Fee Amount* i / <br />Arnount Paid <br />3� Paymeat ari! <br />Payment Type <br />rrrolee# <br />Check # <br />Received By: <br />£HO 4"2-025 l/V I �/ r S vpq g-31,4, SR FORM (Goiden Rod) <br />ES <br />REVIS11!17/1003 ,r d f'1 0 7 -5T 1. — <br />