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SAN JOAQUINOUN,TY ENVIRONWNTAL HEALTH ItAWFIVIEN'I' <br /> 1 <br /> SERVICE REQUEST <br /> Type of Business or Property n FACILITY ID pE R Q EST 11 <br /> Mini Mart H'QQ -� <br /> OWNEIt/OPERATOR <br /> Time Oil Co. , P.O. Box 24447, Seattle, WA 98124-0447 CREAK it BRtMOAoose" <br /> FApun NANc Jackpot Food Mart <br /> SITE ADORES <br /> 14000 E• Highway 88 Lockeford; 95237 ' <br /> HOtIG Or tdAILING ADORSSS or Different from site Addres3) <br /> Time Oil Com an P.0• Box 24447 <br /> Cm' - vet Name <br /> 'Seattle STATE ZIP. . <br /> pHw,if1 EXT. WA 98124-0447 <br /> APN f LAr'1e W!APPUOATIOH B <br /> (209 )727-5441 <br /> PHONC 02 EXT. <br /> ' - 805 D16TRIOT LOCATION Caoa ' <br /> REOUESTOR <br /> CONTRAC'T'OR/SERVICE REQUESTOR <br /> Keith A. Tallia GTECKIf PILLING AOnREss® <br /> BUSINESS NAMI? 'PX0.46N • <br /> Oil -Equipment Service � IXT.20 754-180.8 <br /> HONE or iQAIUNO ADDRass FAX <br /> P x 950 ( 209 754-5726 <br /> CITY San Andreas STATEIp <br /> 9249 <br /> BILLING ACKNOWLEDfPbfpNT: 1, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that ail site and'or project spcciflc ENviRONmgt;rALHEALTH DErARTMeNThourly chargee associated with this projector <br /> activity will be billed to tile or my business as identiricd on this form. <br /> I also certify that I have prepared this ap and that the wor_kAgbe perrormed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordir:dncc Codes,Slandar , A a/ GD `%i^'2j <br /> APPLICANT'S SIGNATURE: DnTtrt�: 12119/02 <br /> I'uorgtSV/tiushvl„cs OwiveRn OPERATOR/MANArex ❑ 0va:RAtrruom7ro AoERT13 Contra .tor/Agent <br /> lTAr;-ueAArr is nor Ilse Brurrac PAR proof of aulkorizalloa ro Sign rs raguved Title <br /> ASITI•IO�N TO RE[ RASP'TNFORMATIONTO RE[ RASE INFORMATION:When applicable, 1, the owner or operator of the property located at the ' <br /> above site address, hereby authorize the release of any and all results.,Scotechnical data andlor cnvironmentaUsi(e assessment <br /> information to 1110 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 OPSERVICEREQUESTEO: o - - PAYMENT <br /> CONNERS; <br /> JAN - 8 2003 <br /> SAN JOAQUIN COUNTY <br /> PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> APPROvEDsY:. EuPLOYEE#: <br /> DATE: <br /> As$IONEOTO: v( EMPLOYSiB: <br /> DATE: <br /> Date Sarvtce Completed d Airaady completed); $ERVICECOOE; <br /> P/E:, <br /> Fee Amount: Amount Paid a Payment 0 le <br /> Payment Type / 3 <br /> Y YP Involco N' Check N�r .Received By- <br /> MHO 48,01-a25 <br /> REMED&e-0a .. Se"Od RZOVEST FORM <br />