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Fl;1H FLUUfC HAUL U2 <br /> SAN JOAQUIN .INTYENVIRONMENTAL HLAI-XI-Ild2'INIINT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID 0 SER�u1JCE REQUEST 0 <br /> Mini Mart � �� 739 S,\ �'G'`j2 <br /> OWNER/OPERATOR <br /> Time Oil Company, P.O. Box •24447, Seattle, WA 98124- eNEexif RiLLRIn Anoriul; <br /> )44 <br /> FACUTY NAM <br /> ..Jackpot Food Mart <br /> SITE ADDRESS <br /> 1434 W Yosemite Manteca CA <br /> ' <br /> 3661 Nam ZIP code <br /> Holli or MAILINo ADmtiss (If aillerent from Site AddreR) p,O. Box 24447 <br /> _ T Ol w D I Wnb� <br /> Crry STATE Zig <br /> Seattle A _ <br /> 0,447 <br /> PNONi NI IT. APN♦ LAND USC APPUGATION A <br /> ( 800 426-0235 <br /> NAONe E2. Exr. 805 tl16TRNn LOVATIDNCa D3 <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REOUESTOR <br /> Keith A. Tallla CNEGNIfBILLING AODRESStX1 <br /> 9USAEss NAME Oil EPHONSA- eAr, <br /> Equipment- Service 209 1 .08 <br /> HOME Or MAILING ADDRESS - FAx( A <br /> P.O. B x 950 ( 2091 754-5726 <br /> On ( 205 <br /> Andreas STATECA zip 95249. <br /> BILLING ACKNOWLEDfrAfq T: 1, the undersigned property or business owner, Operator or authorized agent of sante, <br /> acknowledge that all site andlor Plvject VQClflC ENVIRONMrWALHPALTH DEPARTMLNT hourly charges associated With this Pf0j0d or <br /> activity will be billed to me or my business as identified on this form. <br /> Ialso certify that have prepared this applic that the wo o be pfrformed will be done in accordance withal)SAN JUAQUIN <br /> COUNTY Ordinance Coder,StanMF <br /> APPLICANT'S SIGNATURE: K DATE: 12/20/02 <br /> PROP) TV BU$1Nl=OWNLR❑ OPaIUTOR I MANAuZH ❑ OTIIRa AV17"0RI7no Aorrrr[3_font ra ctor/Agent <br /> /fArPueANT U riot rhe alwNc,PARTY proof of aut6orizatton to sign it squired Title <br /> AUT14OR17,ATI6N TO REI RASTs'INFORMATION:When applloabie,1, tho owner or operator of the properly located at the <br /> above site Address• hereby authorize the release of any and all resulls,,aeotechnical data and/or cnvironmontaltsite assessment <br /> information to 1110 SAN JOAQUIN COUNTY IsNVIRONMENTAL HEALTH DePARTMEM'as soon as it is available and at the same time It Is <br /> provided to me or my representative. <br /> Type orSeRvicEReoueslED: FiEGEIVE] <br /> CONNFMe: <br /> JAN 14 2003 ' <br /> AOUIN COUNTY <br /> PUBLICAN OHEEALIH S RVICES <br /> s .ENVIRONMENTAL HEAT TH DIVISION <br /> APPROVED Y' P.awLovEiA: .��SG, DATE: -/ —�`j <br /> ASSIGNED TO: �� EtnPLDyaa Ai 8•.7j / <br /> DATE:Q —/J�—03 <br /> Date Service Completed (if alma ): - SERMCODE! MA PIE <br /> Fee Amount: -24 71 02& Amount Paid Payment Dale <br /> Payment Typo Invoice A''. Check A, .Received Bin <br /> RaVISUD 6•542 •. 3CAVIGC REQUEST FORM <br />