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SAN JOAQUIN COUNTY ENVIRONMEN'T'AL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of l3tisiness or PropBtty FACILITY Ip# SERVICE REQUEST# <br /> Convience StoreEA:C,-w0Cfl4 <br /> OWNER I OPERATOR CNE01(lI SILLINb AbORESS�I <br /> FACILITY NAME <br /> Fast N Esy#116 <br /> Stye ADDRESS <br /> 1399 st19Ct umber D1 =E. semite3Av e, s ManN a 9z�536 <br /> HOME Or f/IAILQto ADDRESS (If niffersnt from$Ile Address) <br /> Sfroat ba stmotflame <br /> CITYSTAW zip <br /> PHONE fit APN Wj)USE APPLIGAYIou# ^ <br /> ( 1 <br /> PNaNE#2 E%t, BOS DISTRICT LOCATIoN CODE! <br /> I l <br /> CONTRACTOR/SERVICE REQUESTOR nn <br /> REQuEsTOR CHuox If f31I.LINo ACPRgsLDt <br /> Bonnie Garber <br /> SUSINasa NAME PffoNE# tr7• <br /> nnniep Pump Company 7-9396 <br /> Homu or MAILING AwRESS FAx# <br /> ( 2091 537-9398 <br /> CI16eres STATE CA. ZIP 95307 <br /> �3ILLING ACKNOWLEDGEMENT: I, the undersigned proporty or bodiless owner, operafor or authorized ft}lent of sanic. <br /> aeknowledgo that nil site and/or proieot speoirte I:NvIROWNiENTAI,1-11?ALTii DEI)AItThrENT llotlrly charges associntott with this project <br /> or activity will he billed to nie or my bimNess as identified on this l'onn. <br /> I also ccrlity that I have prepared this applioation and(lint(he work to be poifoirned will be dtlno in accordance with all SAN.'J0A0t:1�1 <br /> COUNTY 0),dhlonce Codes,.Slandar fs,S'rAw and FFI)YRAt.iaWs, <br /> APPLICANT'S SIGNATURES �-I <br /> PROPERTY/13f1,ST;wiNOwNFRi:3 OPERATOR , ANX;RR0 OTTiwAvritonizEUA(;KVT® gervice Agent <br /> 1f,d1'1'L1C.9W1'1,S 11011110 BILLINO PART)',proof of allthorizatfon to sign is regn1red ills <br /> AUTHORIZATION TO RELEASE INFURMATION: when applicable,1.Ilia owner or operator or the properly located Ill the <br /> above site address, heraby authorize the release of any and all results, geotechnical data and/or cavironmen(allsitc asw."inenl <br /> iltforillotiotl to the SAN ToAQUIN COUNT)'i.sNVIROhr CNITAL HEALTH DPPART\,fiNT ns soon AS it is avaihlhle and at(he sninkr4une it is <br /> provided to 1110 Or Illy ropTosentative, R yy <br /> TYpt;op fi£ftma REQUESTED: <br /> COMMENTS: <br /> (12130115) Replace Veeder Root annular sensor.L-10 tii�QUoy �� <br /> j�O's, �V� Vri, <br /> AcORPTEID 13Y: R EMPLOYEE#: DATE: <br /> AssioNeo To: ` f Empt OYES#: DATE; 3� <br /> Date Service Completed (if already completed): SERVICECODE: Pi <br /> Fee Amount: . 310 �,/ Amount P 7�,� Payment Date l� <br /> Payment Typ � volts 6 Ch # 6 30,/o/ Rea ivad By.e��� <br /> EHD 48.02.025 SR FORIA(Golden Rod) <br /> REVISED 11117/2003 <br />