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2/U2/26U2 15::7 2634063433 FIFTH FLOOR PAGE 02 <br /> SAN JOAQUI OUNTY ENVIRONMENTAL HEALU-101AR'I'MEN'1' <br /> SERVICE REQUEST ' <br /> Type o1 Business or Property FACILITY ID# SERY!JCE REOUEST N <br /> Mini Mart <br /> OWNER/OPERATOR <br /> Time Oil Co. , P.O. Box 24447, Seattle, WA 98124-0447 CNEci ifeLunc aooness❑ <br /> FAciurY NAME <br /> Jackpot Food Mart <br /> SITE ADORES& <br /> 14000 E Highway 88 Lockeford 95237 <br /> $InRI NRI1M city. ZI Ce <br /> HOME Or MAILING ADDRESS (it Different from Site Address) <br /> Time Oil Company, P.O. Box 24447 <br /> CITY STATE ZIP <br /> Saar 1 � WA 98124-0447 <br /> PNonE III an. APNW LANO Use APPLIcAnon N <br /> (209 ) 727-5441 <br /> PNONS N2 DT. 805 DISTRICT Looatloit Ca oc <br /> _ CONTRACTOR/SERVICE REQUESTOR <br /> REOUESTOR -- <br /> Keith A. Tallia CNECKIUeauna ADDRESS® <br /> BUSINESS NAME 'PNONEN'., CRT. <br /> Oil Equipment Service 20 754-180.8 <br /> HOME or MAILING ADDRESS PAX# <br /> P.O. Box 950 ( 209) 754-5726 <br /> Dfry San Andreas STATE P <br /> B(LI,tNG ACKNOWLEDGEfvfFNT: I, the undersigned propertY or business owner, operator or authorized agent at sane, <br /> acknowledge that all site and/or prDJect Specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges d9SOClated with this projector <br /> activity will be billed to nit ur my business as identified on this form. <br /> I also certify that I have prepared Ey <br /> nd that the work tube performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance codes,standeGD !� <br /> APPLICANT'S 5IGNATURI3: a DATu: 12/19/02 <br /> PROP eary l UUSIMSS OWNEIt❑ OMHATOR/MANArER ❑ 0rimRAUTUOmyGo AOSNT3 Contractor/Agent <br /> IfArrucANT is not tha BrurNr,PARTY proof of audtoriwion io.sign it required Titre <br /> AUTI-10IS17AT16N TO REI EASE INFORMATION:When applicable, I, the owner or operator of the properly located at the <br /> above Site address, hereby authorize the release of any and all results,,geotechnicat data and/or environmental/site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DePARTMENT as soon as it is available and at the Sam(;time It Is <br /> provided to me or my rcpresenlative. <br /> TYPE of SERVILE R400ESTED: <br /> J <br /> COMMENTS: ' <br /> APPROVED BY: EMPLOYVK#: IS; / D <br /> AssIGNEDTO: v ( EMPLOY610: -DATE: <br /> Date Service COmpletOd dalready completed): \ SERVICECooE: PIE:, 1 <br /> Fee Amount: Amount Paid Paymant'D to <br /> Payment Type Invoice BCheck k Received ST. <br /> EMD 43,CI.025 <br /> RIIVISED e3-0a SEAVICE ReWEST FORM <br />