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SARI JOAQDIN COUNTY UNVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID—# SERVICE REQUEST#! <br /> Convience Store FAooC,OG 1 �• lq <br /> OWNER I OPEAA'TOR CHECK If BIL LNI0 ADDROSSED <br /> FACILITY NAME <br /> Fast N Esv#116 <br /> SITE ADDRESS <br /> 1399 sttaetN mbar e E. YosemitesAv e� e Manta a 9z3d6 <br /> HOME or MAILING ADDRESS (If Olfferent from Site Address) <br /> 3lraatNumbs StreotN mo <br /> CITY STATE ZIP <br /> PHONE 01 APN# LA11D Uar:APPLICATION# <br /> PHONE#2 Ext• BOS DISTRICT LOCATION CODE <br /> ( l <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR <br /> nie Garber CNeCKirBILLIttoA0oRt3SSi.Gt <br /> Suswrzsa NAME PHONE 4 <br /> Company 37-9396 <br /> Homn Or MAILING ADDRESS FAX III <br /> 989.1i R.Alroad Ave- ( 209) 537-9398 <br /> ClTG4eres STATE CA, ZIP 95307 <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned property, or business owner, operator or authorized agent of sante, <br /> aoknowledgo that nil site and/or project speOMO ENVIRON:;VNITAL HnAi,Tti DEPARTMENT hourly ehnrges associated Nvith this prt jcct <br /> or activity will he billed to me or my business as identified on this tori. <br /> 1 also cc riily that I have prepared this application and that the Nvork to be performed will he dano in accordance with all SA\JOAOI:I'1 <br /> (btINTY Urr#frtrnree Coc#es,SYanclarc#s,S't ATL'and FRI)FRAI taws, <br /> APPLICANT'S SIGNATURE <br /> PROPERTY/l3usumss OwNRR1 3 OPPR&TOR/NuNAWR 0T3iEItAP'ruoRiz>t),k(;., ' geryice.Aaent _ <br /> If At,nia,4,vr Isnot the BiLumo Mrn proof of authorhatlon to,sign is regcrtred T rt c <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1,tic otYncr or operator Or the property located nl the <br /> Above site address, hereby authorize the relonse of any mid all results, geo(eohttieal data ►Itld/or cmironmen(IIl/sitc as �Ukent <br /> information to the SAM JOAQUIN COUNTY 13WIRONAit i;TAL HRAI.vi DEPARVVE+NT AS Soon flS it iS aVfltlable and at Ih�sarn��i�{L,�N7, <br /> provided to me or my representative. FAV <br /> TYPE or Si tv10E REQUESTED: say3,0 9 <br /> COMMENTS: <br /> (2111/15) Replace Diesel relay <br /> AcoapuD BY: EMPLOYEE?t#: DATE: C-1// <br /> AssIGNED To: M A EmnoYEE M DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: <br /> Fee Amount: 3 3 7U Amount Pa 7X0.00 Payment Date 1 <br /> Payment Type ��� It6olce W, kp�7/ RecefuedBy: <br /> EHD 48-02.025 d3�/ ( SR FORIA(Golden Rod) <br /> REVISED 11/17/2003 <br /> I <br />