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.2;'02/2702 15:.7 2794663433 FIFTH FLOUR PAGE 02 <br /> SAN JOAQUOOUNTY ENVIRONMLNTAL I' EAUr*l'ARTMI NT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID i BE IVICE REQUEST S <br /> Mini Mart <br /> OWNER/OPERATOR i <br /> Time Oil Company, P.O. Box 24447 , Seattle, WA 98124- CHECK iT BILL wo.ADonitss❑ . <br /> FACILITY NAME <br /> Jack of Food Mart <br /> SITE ADDRESS <br /> 1434 W Yosemite Manteca CA <br /> 1 1 snoAl NamA cliv Zln Code <br /> HOME of MAILINti ADDRESS (It oularent from Site Addre33) P.O. Box 24447 <br /> Time OilCamp-any fiDet N.me <br /> CrfY STATE 21P. <br /> Seattle WA 98124-0447 <br /> PNONi SI P.n. APN,# LAND Use APpucArlonN <br /> ( 800 426-0235 <br /> PNONC ax Ear. BOS DIeTRICr LDpATIDN ODDS ' <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REGUESTOR <br /> Keith A. Tallia CHECK R BILLING ADDRESS <br /> BUSINESS 14AME PRONES , for, <br /> Oil Equipment- Service _ <br /> HOME Or MAILING ADDRESS FA%k <br /> 1808 <br /> P.O. Box 950 ( 2091 754-5726 <br /> C" San Andreas STATECA ?IP 95249. <br /> G ACKNOW L DCEMP.NT: 1, the undersigned property or business owner, operator or authorized agent of sanm, <br /> acknowledge that all site andfof project specific ENVIRONMENTAL HEALTH DuARTMGYr hourly Charges associated with this projector <br /> activity will be billed to me Or my business as identified on this form. <br /> I also certify that I have prepared this applic that the wo o be pprformed will be done in accordance with all SAN JOAQUV+ <br /> COUNTY Ordinance Codes,Stan �F <br /> APPLICANT'S SIGNATURE: K DATut 12/20/02 <br /> PROPERTY/HuSINUssOWNL'RCI 0MRATOR/MANAr,IRO OrnaRAuTnt;nu7aDAGrmT[3 Contractor/Agent <br /> /fAPP6tcANT Is not the BrurNg PARTv Praof of auiliotkatiort to sign it required rate. <br /> AUT1dOR TZATION TO REI 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 resulls,,geotechnical data and/or environmentaUsite assessment <br /> information to the SAN JOAQUIN COUNTY F.NYITONMEINTAL HEALTR DEPARTMENT as soon as it is available and at the same time It Is <br /> provided to me or my representative. <br /> TYPE OF SEAVICE REQUESTED: U�j <br /> COMMENTI; <br /> AVPROvQo V, EMPLOYEE#: G'9b ' DATE: �`j <br /> ASSNJNEOTO: �� ELPLovas0: g_3 �7 � DATE: <br /> Date Service Completed (if alma ): SEAwee CooE: �G18 PIE: x.305'' <br /> Fee Amount: m� G2> Amount Paid .Payment Date <br /> Payment Typo Invoice k'. Check k. Received By: <br /> IND 4&111425 <br /> RIVISSD s•s-02 3EAVICa RIOVEST FORM <br />