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- -� SANJOAQUINOUNNYENVIRONMENTALHEALT1'7*ARTMIWr <br /> SERVICE REQUEST <br /> Type of t3usiness or Property FACILITY ID N 6 R1(JCE REOUEST N <br /> Mini Mart Arc 7 <br /> OWNERI OPERATOR <br /> Time Oil Co. , P.O. Box 244.47, Seattle, WA 98124-0447 CNFCN if 0I141!9AOonE88 <br /> FActun NAME <br /> Jackpot Food Mart <br /> SITE ADOMS6 <br /> 14000 E. Highway 88 Lockeford; 95237 <br /> Street N3M CII ZI Ce <br /> HONE or MAILING ADDIIESS (It Different from SRO Addreao) <br /> Time Oil Com an P.O. Box 24447 <br /> CrrY °' s IName <br /> _E' t t-1 c, STATE <br /> S a 'QIP <br /> pNONEIII EXT. WA 98124-0447 <br /> (209 ) 727-5441 <br /> APNN LAND USC APPLICATION 11 <br /> PHONE N2. ¢✓•T. 805 b1¢TRH:Tr <br /> LOCATION CODE- <br /> REOUESTOR <br /> CONTRACTOR/SERVICE REQUESTOR <br /> --- <br /> Keith A. Tallia CHECK N BILLING AonRess® <br /> 13USMESS NAMC - ' <br /> Oil Equipment Service PHON6N ear. <br /> 20 754-180.8 <br /> HOME or MAILING ADDRESS FAX M <br /> P950 ( 209 754-5726 <br /> CITY San Andreas STATE P <br /> CA <br /> 131LLiNC ACKNOWL 1)fFML+NT: I, the undersigned proyCrtY oY business owner, operator operator authorized agent of same, <br /> acknowledge that all site Andlor project specific ENVIRONMIDNAL HEALTH DEPARTMENT hourly charges associated with this project or <br /> activity will be billed to me or my business as Identified on this form. <br /> I also certify thatI have prepared t!Vrz <br /> nd that the wor be performed will be done in aecordance with all SAN JpAQUW <br /> COUNIY Ordnance Codes,Slande '%�" <br /> APPLICANT'S SIGNATURB: <br /> DnTs: 12_/19/02 <br /> PROP.FIITV/UUSINrtss owNERLI OMIATOR/MANAGER ❑ OTImtAuntoRIT,ryo AGENT C'On ra O /A n <br /> IfArPuenNT If not the Sru mr;edR v proof of aalhorigattoa f0 sign is required Time- <br /> A TtX T;I�ATION TO RBI RAS INFORMATION:When applicable,1, the owner or operator of the properly located at the <br /> above altc address. hcre6y authorize the release of any and all results,,aeotechnieal data and/or cnvironmantaUsile assessment <br /> information to for SAN lOAQUW COUNTY ENVIRONMENTAL HEALTH DWARTMENT as Soon as it is available and at the same time It Is <br /> provided to tree or my representative. <br /> TYPEOPSERVICEREQUESTED: PAYMENT <br /> COMMENTS: <br /> JAN - 8 2003 <br /> SAN JOAQUIN COUNTY <br /> PUBLIC HEALTH SERVICES <br /> ENVIRCNMENTAI HEAI TR DIVISION <br /> APPROVEDIDY: EatPLeyes tl: / Z' O <br /> DATE: <br /> ASSIGNED TO: vUX EmpLQYiip: <br /> DATE: <br /> Date Service Completed If already Complatad); SERVICECOOE: <br /> Fee Amount: Amount Paid .payment n-le <br /> Payment Typo Invoico N' Check k <br /> RecoivetlBy: <br /> END as cT-Dzs <br /> REVISED 6.542 •. SP"ra RCQUEaT FORM <br />