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SAN JOAQUIN COUNTV ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />Convience Store <br />FACILITY Ip # SERVICE REQUEST # <br />irj) 4 % <br />OWNER /OPERATOR <br />CHEOK If BILL No ADDRESS <br />FACILITY DAME <br />" <br />SITE ADDRESS <br />1 ESS <br />6tf90t at8f <br />... Drinlen Pump Company <br />E. Yosemite Ave. <br />sfreet Name <br />Mante <br />95336 <br />ZI Gado <br />HOME Or MAILING ADDRESS (It Different from Site Address) <br />SlrOotNumker <br />Swat Name <br />CITY <br />STATE Zip <br />PHONE #1 RXT• <br />t <br />APN tl <br />LAND U9E APPLICATION N <br />PHONE#2 Ext, <br />( 3 <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR I SERVICE REQUESTOR <br />RE:QUESTOR <br />l CFN <br />BQnnieb <br />CHECK If BILLItfO AODRassm <br />BuslNG&s NAMES <br />" <br />PHONE # EXT. <br />... Drinlen Pump Company <br />1209) 7-9396 <br />HOME or MAILINQ ADDRESS <br />EMPLOYEE #: <br />FAX# <br />9A95 Railrond AVP, <br />EMPLOYfiE#; <br />( 209) 537-9398 <br />Cll&res <br />STATS CA. ZIP 95307 <br />BILLING ACKNOWLEDGEMENT: I, the undersigned proper(y or business owner, olierator Or authorizetl agent of Same, <br />a0,1•nowledge that nil site and/or pr( ieot speeitie RNVIRONNUNTAI, I-lFAt.Tti Dm)ARTNIEW hourly Charges nssocintetl Willi this project <br />or notivity' Will 1)c hilted to n)e or riy business as identified on this fonu. <br />I also ccrti(that I have prepared this application and that tho work to bo perf'onned will ho dono in accordonco with fill SA\ Jv:u0t t,r <br />COUNT)' Urd/rr011CO Codec, S7�rrrrr'nrtls, ,S'rATL' and FEMRAI, IMS, <br />APPLICANT'S SIGNATURE;Q, D,YPF: <br />PROPERTY IBIT-4r1MOWNER ❑ OPfMATOR/, 111F.R ❑ OTHERAtrrHOlima)A(,.Y,,w SP rvCp Agent <br />11,1r/'4te t yr !.r rent the RILL/Ar0 PAIif!'. proof of authorizatlon to slgs is required Y'irt e <br />AUTHORIZATION TO RELEASE INFORMATION: When applicnblc, T, the n)Ynev or operator ot'the property' loonted al the <br />above -site riddrom, hereby authorize the relonsc of any and nil remits, geotechnicnf data fuid/or enviranmentallsite assessment <br />infortuntion to the SAN .TOAQUIN COUNTY NVIR0N,\4HNTAL 14L?AI,Ttt DrPART&fENT ns soot) 8s it is avnilallo and al the sante lime it is <br />provided to nm or my representative. Aq <br />TYPE OF SERIAGE REQUESTED: <br />l CFN <br />COMMENTS; <br />JUN <br />o? <br />Replace 87 Turbine Red Jacket LLD due to failed testing. <br />" <br />ou <br />H��O aM H�U <br />gRTM <br />Aoci rTeD BY: <br />EMPLOYEE #: <br />DATE: S , <br />ASSIONEOTO; <br />EMPLOYfiE#; <br />DATE; b_..._ <br />Date SOIVICO Completed (If already completed); <br />SERVICECODE: G <br />I E: <br />Fee Amount: 0 3 p <br />Amount Payment Date <br />Payment Type _ <br />I-Invofce # <br />Ch # <br />77 <br />Received By:GJ3 <br />END 48,02.025 SR FORPA (Golden Rod) <br />REVISED 11/17/2003 <br />r <br />0 <br />e <br />