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SAN JOAQUIN COUNTY ENVIRONMk1NTALHEALTHDEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Convience Store 1)60 / S�b�51 <br /> OWNER/OPERATOR CHECK if 13111.10 A00RESS� <br /> FACIuTY WE <br /> Fast N Es #116 <br /> SITE ADDRESS -T <br /> 1399 E. YosemiteAve. e 1-..--Mantq&a 9z�5 36 <br /> NOME Or MAILING ADoms (if different from Site Addroas) <br /> SltaolNum6oT 5trnolName <br /> CIT' STATE zip <br /> AP U N I-Anp U89 APPLIOA110 N# <br /> ( 1 <br /> PHONE M EXT. BOS DISTRIOT (O'Avon Cou <br /> i 1 <br /> CONTRACTOR I SERVICE REQUESTOR <br /> REQUESTOR n <br /> die Garber Oxeolclf HIlL1N0A17DRHSSBon �n <br /> l3uswuss NAME PHONE# srr- <br /> .. Donlep Pump Company 37-9396 <br /> HotdR Or MAILINo ADDRESS FAX# <br /> 9895 Railroad Aye, ( 209) 537-9398 <br /> C1T6eres STATE CA. ZIP 95307 <br /> �iILI,I IG ACKNOWLEDGEMENT! I, the undersigned proper--t• or business owivor, operator or authorized agent or same, <br /> acknowledgo that All site And/or project speoifia HWIROMUNTAT,I1T?ALT1i Din)ARTMENT hourly charges associated Willi this proicct <br /> or notivily will be billed to nle or m y buvhless as identified on this terns. <br /> I Also certify that I have prepHred this appHoation and that the SYOrk t0 be pul'on)led will be don0 in accordance Willi all SANT JOe OUIN <br /> COUNT'Ur(1111anccl Codes,S1011dahls,STATL and FrDERAL laws, <br /> APPLICANT'S SIGIVATUI2Et DAtF;; 3t� �,t <br /> PROPERTY/BU,ti1,nss awNP,R❑ oPHRATO /i ANAGER ❑ OTnaAUTHORinD iAoym'M SPrince Aaegt <br /> If,�it'1't re,lM Is nol Ike 13/ xya A.Elrrtproof of aut/1or1taQorl to sign 14 regnlred ivrle <br /> APTHORIZATION TO RELBASE INFORMATION, When applicable,I,the miner or operator ot'tlte property loented al (lie <br /> above site address, hereby authorize tho retcase or any and all results, geotechnical dnia and/or onvironmentitUsite Asics-miew <br /> illfOrinatioil t0 the SAN JOAQUIN C 01),NT)')?NVIRONAdENTAL HF-AT.Tft D'FPAWf\df NT as 50011 as it is available and at(110 Hanle tithe it i, <br /> provided to mo or my reproscntative. A,q <br /> TYPE OF SERVICE REQUESTED, <br /> COAMEYTS: <br /> (1/7/16) Replace 87 Turbine Red Jacket LLD due to failed testing. h 0 a OSS <br /> oFaq,4�,�'hy <br /> E� <br /> Ac0EPUDBY! t liMPLOYEE#: DATE: <br /> A881GNE0 T0: RMpt.oYDE#: DATE: <br /> Date Service Completed (If already completed): SEAVICECODE: 5/ P1 E:Z_ U. <br /> Fee Amount: 3`�'�� 3� Amount P-aq7F C(j payment Date <br /> Payment Type / invoice# Ch k# d3��7 Recel ed ay: <br /> EHD 46-02.026 SR FORM(Golden Rod) <br /> REVISED 11117/2003 <br />