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COMPLIANCE INFO 1997-2004
EnvironmentalHealth
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EHD Program Facility Records by Street Name
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2300 - Underground Storage Tank Program
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PR0231431
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COMPLIANCE INFO 1997-2004
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Last modified
2/9/2024 10:59:45 AM
Creation date
11/7/2018 4:09:52 PM
Metadata
Fields
Template:
EHD - Public
ProgramCode
2300 - Underground Storage Tank Program
File Section
COMPLIANCE INFO
FileName_PostFix
1997-2004
RECORD_ID
PR0231431
PE
2361
FACILITY_ID
FA0000514
FACILITY_NAME
MAIN STREET SHELL*
STREET_NUMBER
1071
Direction
N
STREET_NAME
MAIN
STREET_TYPE
ST
City
MANTECA
Zip
95336
APN
21707011
CURRENT_STATUS
02
SITE_LOCATION
1071 N MAIN ST
P_LOCATION
04
P_DISTRICT
003
QC Status
Approved
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\MIGRATIONS\M\MAIN\1071\PR0231431\COMPLIANCE INFO 1997-2004.PDF
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EHD - Public
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^' SERVICE REQUEST <br /> FACILITY 1D# SERVICE REQUEST# <br /> 2ess Property -�V` p' <br /> + , $SLUNG PARTY 11 <br /> f , g 5TP, fr1 <br /> �i� � ASG 0jJ� f r 7'+ ENV1R�}VENTHEAL N <br /> /� ,M Soz.eHum. ERMITISES TYr*/✓ StrMNumC*r oirx7an 1 <br /> Mailing Address of Different from Site Address) <br /> NATE - zlp� 5- S J <br /> lu <br /> CITY MAN T 0� ,/ <br /> �. APN# LAND UsE APPLICATION# <br /> PHONE#1 <br /> -r, 3-7(, 130S DISTRICT Lrxa.TIGN CGDE <br /> PHONE#2 <br /> CONTRACTOR 15ERVICE REQU ESTQR <br /> Btt <br /> • ttxG PARTY❑ <br /> REQUESTOR <br /> PHONE# / ! �. <br /> BUSINESS NAiAEWAI� L rJ n t 9✓L tv �f� 41a <br /> L FYI FAX / r <br /> MAILINGADOREss O n <br /> k STATE [A Z]P % g <br /> Cm Sh-'}G &An-44r-rV <br /> e or business owner, operator or authorized agent of same, acknawfedge that all site and/or project SPe�c <br /> BILLING ACKNOWLEt GEMENT: I, the undersigned property ora will be billed to me or my business as identified on this loan. <br /> PUauc HEALTH SERwi:S E-WrRcN4MENTAL HEALTH ONIsi N1 hourly chages assodated with this project <br /> I also certify that I have prepared this appGcas on and that the work to be performed wilE be done in accordance with all SAN JGAOUIN CouNTYQOrdinance Codes,Standards.STATE and <br /> FEDERAL laws. <br /> DATE* <br /> APPUCAHT SIGNATURE: 124 j YL1 <br /> OPERATORI fvIAJIAGER OTHERAUTHMT-DAGENT r;ue <br /> PRCPERTY 1 EuSINESS OWN It APR)CA r is fxt Its P-p Prof of sudwr z2dba to sign ks reWrod <br /> AUTNOR�ATION TO RELEASE INFORMATION:When applicable,1,the owner or operator of the property k)cated at the above site address,hereby authorize the release of <br /> any and aa rE TIOufts.geOteG ELF6mf data INFandlOr envirt7nmentaV5i 8 assessment information to the SAN JOAQUIN COUNTY PUBLIC HICAALTH SERVICES EWRONMENTAL REALM ONIS"as soon <br /> as it is available and at the same time R is provided to me or my representad're. <br /> FTYOF SFRVSCE RE4UESfED: 1MEHTS: <br /> PAYMENT <br /> RECEIVED <br /> PUBLICAUUIN COUNTY <br /> HEALTH SERVICES <br /> FNVIRONPAEN'KkL HFAITH DIVISION <br /> LA-- <br /> CONTRAOTOR'S SIGNATURE: <br /> INSPECTOR'S SIGIIATURE: C <br /> CAT?w' �r <br /> APPROVED BY: ; r C Q f� <br /> EMPLOY E€#: r] `✓ DATE Cj <br /> ASSIGNED TO: SEMOCKCIEC4DE: ..• .:� �.�� 1-31) <br /> Date Service Completed (f already completed): <br /> - Amount Paid , Payment Date <br /> Fee Amount Received By: <br /> paymen#Type <br /> Invoice# Cheek# <br />
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