Laserfiche WebLink
SAN JOAQUIN COUNTY 1VNVIRONMPNTAL HRALTH DFWARTME,NT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Convience Store <br /> OWNER/OPERATOR CHEOK if�1LLINeAL1QRHssL� <br /> FACILITY NAME <br /> SITE ADDRESS <br /> TE.Yosemite Ave. <br /> 1399 8tlaat umbo o sires, Mante 95336 e <br /> HOME Or MAIUNO DRESS (it oifferent from Site Address) <br /> Sl►ootNumBa► sugat?-lama <br /> CITY STATE zip <br /> PHONE 91 E APN# LAND Um!APPLICATION# <br /> PROH£#2 EXT. BOS DIsTRIOY LOCAvon CODE <br /> ( l <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQuEism CHECK If Ha.L1140 AODRBSS <br /> Bonnie,Garber _ <br /> Susmass NAME PHONE <br /> Dnnfpp Pump Company 7-9396 <br /> HOtm Or MAILiNQ ADDRESS FAX# <br /> ( 209) 537-9398 <br /> ciTCXeres STATE CA. ZIP 95307 <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned property or builness owner, operator or authorized agent of sane, <br /> aatttowledge thAl All site And/or proieot Speeitic F:NVIRO,rl,3l?N TAI,I•IEAITHDFI>AttT\CENThourly ohnrge,assoeinted with this proiec( <br /> or notivity will eta billed to itte or ity business as identified on this 110nil. <br /> I Risk)cerlit`y thai I have prepared this application and that(howork to bo porfonned will bo done in aecordnineo With all SAN,70A0t:l't <br /> C011INTY Orelhionce Codes,,S'/rlllrlQlc/s,$'rATL'and Fr,on-RA1.111WS, <br /> APPLICANT'S SIGNATURE; AyadD,s.t,,.;; X30— 2 <br /> PROPER'r1'/BUSr\t?SSOWNFRO 'OPXRATOR/i Nd(WR � OTUERAtvfH0Itu't)A(1F:in'IAI SP.fVICP.Agent <br /> Il',41,Ph1e rNr Is not the BiLL1NO Pd1rn proof of authorization to sign 1s re(pilred YYrte <br /> AUTHORIZATION TO RELEASE INFORMATION; Whon applicable,1,the otvnei'or operator or the pro1wrty loonled al the <br /> above-site adtlitse, hereby authorize the reloase or Any And all results, Scolcchnicol data andlor onvirotmletltalAile aasossulent <br /> infortttatiou to the SAN JOAQUIN COUNTY ENViRONMEWAL 14LA1,T1-[DnPAU&I-RNT RS SOotn AS it is M1011blo Milt ill 1110 Si11110 6111C it 1\ <br /> provided to mr,or my representative. Aq <br /> TYPE of SERmcE REQUESTED: l FCF/V D <br /> COMMENTS: JU <br /> Replace 87 Turbine Red Jacket LLD due to failed testing. '�0 3�? 6 <br /> �+o�, <br /> H ��pMF <br /> . ARrMFe, <br /> Aow7eD BY: EMPLOYEE#: DATE: <br /> AsStaNED 70; EMPLOYOK#; DATE: <br /> Date Servlao Completed (if already completed): �� SERVICeCODE: Gtr f i. / b_ <br /> Fee Amount: j 0 3 © Amount P wd.d z) Payment Bate <br /> Payment Type _ Inv ce# Ch # (3301 Received Sy:L�Lv <br /> EHD'18-02.026 St2 FORM(Golden Rod) <br /> REVISED 11117/2003 <br />