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so ft <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Propatty FACILITY ID# SERVICE REQUEST# <br /> Convience Store FA- QW 090iq f2) <br /> OWNER t OPERATOR CHEOK If BILLfeo ADDREsst...f <br /> FACILRY NAME <br /> Fast N Esy#116 <br /> We ADDRESS <br /> 1399 stiQAl m6or D o E. Yosemite Ave. s Mantes a —L—9zu3d6 <br /> NOM&W MAII.WaAnonsS (if Different from Site Address) <br /> 9lroofHum6e strcalN ma <br /> CITY STATE zip <br /> PHONEM E'R• APN4 LAUD USHAPPLICATION# <br /> { ) <br /> PRou02 Ext. 608 DISTRICT LOCpTIONCDDE <br /> ( 1 <br /> CONTRACTOR/SERVICE' REQUESTOR <br /> REQuESTOR (� <br /> ' Garber 0190K It 61LLINC AOaasss-BonnL3i <br /> BuaiNaea NAME PHONE# E't <br /> nonlee Pump Company7-9396 <br /> NOME Or MAILING ADDRESS FAX# <br /> { 209) 537-9398 <br /> Ctr6eres STATE CA. ZIP 95307 <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or busincs.4 mviier, operator or authoriyed agent of sante, <br /> adnowledge that nil site and/or proiect Specific ENvIROM,ir-NTAI.11FAmniD:1'ARTNIENT110u1.1y Charges assooilited with this protect <br /> or activity will he billed to nue or Iny business as identified ort this forill. <br /> I also certify that I have prepared this application and that tho work to bo poifonned will bo dorso in accordanoo with all SAS TC)A0VIV <br /> C011NTY 0)-dilIaI10clC0cles,%011laTllr,S,nxTLi,aitd Fr,.DERAI,IaWs. <br /> APPLICANT'S SIGNATURFi a..r.2L f( DA rr;: �0`Z <br /> PROPHRTV/BU51,\TiSgOWNYR❑ OPP.RATOR/Mf AGIXR 13 OTHERAUTHORIZEDAGENTM Service Agent._- <br /> If,,Il'/'LICANr 1.5 nol the RILLINO PAterl'.flr00f of autherlrallon f0.Ign 1v required 'I'111e <br /> AUTHORIZATION TO RELEASE INFORMATION. When applicable,I,the nwner or operator of(lie properh' loonted al the <br /> abovo site address, heroby authorize the release or ally nlld all results, geotechnical da(n and/or 0ltvironntentallsite nssessnient <br /> iuforntation to(110 SAN JOAQUIN C01jNTY lMtRt3mmrrAL 14HAI.'TI-I l)IzPART.LtrNT M SOOIl as it is IlV6101110 alld tit Ille sallM(Illlc it 1, <br /> provided to ma or my representative. Aq y <br /> TYPE OF SERVICE REQUESTED: tc�CF/V T <br /> COMMEnTS: <br /> (7/2/15) Replace Veeder Root annular sensor E_-8 s+v 4 �?0 <br /> F,yr <br /> AcaEPTED BY: EMPLOYEE#: DATE: 3b <br /> AsaloNaOTO: Empi oYf4R#: DATE: 30 <br /> Date SerVloo Completed (if already completed)' SERVICECODE: Pl E: � K <br /> Fes Amount: _ mount Paf yb, Payment Date <br /> PaymentTypell in tee id By: <br /> END 4"2.026 SR FORM(Golden Rod) <br /> REVISED illi712003 <br />