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SAN JOAQDIN COUNTY ENVIRONMENTAL HEALTH MPARTIvIRNT <br />SERVICE REQUEST <br />Type of BuRIness or Property <br />FACILITY ID # SERVICE REQUEST # <br />Convience Store <br />FA o00 oq I S <br />OWNER I OPERATOR <br />CHEOK if <br />PHONE Ext. <br />BlLukn A ess L! <br />FAciLiTY NAh1E <br />37-9396 <br />Fast N Esy #116 <br />Evr <br />SITE ADDRESS <br />9A95 Ranlrogri &P- <br />EMPLOYEE i1: <br />( 209) 537-9398 <br />CIteres <br />STATE CA. ZIP 95307 <br />1399 trtroetNumb�r <br />e <br />E. YosemitesAaHama e. <br />Mantes a 7 <br />92UA9 <br />HOME Or MAiLING ADDRESS (it Different from Slte Address) <br />it: : eZj�� <br />Fee Amount: O Arnount POW780,00 <br />Payment Date <br />Strootkumbe <br />S<reetN mo <br />CITY <br />Payment Type �� I olce <br />STATE zip <br />PHONE al <br />t 1 <br />APN N <br />LAND Use APPLICATION # <br />PHONE #2 Ext. <br />t ) <br />003 DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE RE'QUESTOR <br />REQUESTOR <br />— Bonnie Garber <br />OHBCtc If BIt t Ik0 ADDRH&e W! <br />Busimess NAME <br />PHONE Ext. <br />Company <br />Fps <br />37-9396 <br />HOME' or MAILING ADDRESS <br />Evr <br />FAXN <br />9A95 Ranlrogri &P- <br />EMPLOYEE i1: <br />( 209) 537-9398 <br />CIteres <br />STATE CA. ZIP 95307 <br />I-ILLING ACKNOWLEDGI+.MENT: I, the undersigned property or business myner, operator or authorized agent of sante, <br />aoknowledgo tint nil site and/or project Speoitie ENViRONMENTAL I•II?Al.Tti DEPARTMENT hourly oharges assoeinlod wilh this project <br />or activity will be billed to me or my hustaexx as identified on this torn). <br />1 also certify that I have prepared this applioation and that the work to be perl'onned wili be dono in necordonce with till SANT JOA011\4 <br />COpNTY UIYif lance Cocks,.S'lonclarcls, ,S`t'ATL' and FRURAI., laws, <br />APPLICANT'S SIGNATURRE 114 Dxr>;: <br />PROPERTY/ BUSIXES30WNERE3 OPERATOR/, N. GER Q 0TN6EtAttTHORIUDAGKNt` 0 S _rV� i , , Agent__ <br />if ltt'ate.�rrr !s trot lire RILLINC3 P.ttrr}', proof of ai4iltorizotlott to slger is regrrlred Tt tle <br />AUTHORIZATION TO RELEASE iNFORMATION: When applicable, 1, the owner or operator or the properh• locntcd nl the <br />above site address, hereby authorize the rolonse or any and all results, geolcchnioal data andlor environmental/site as -p- opcnt <br />information to tho SAN JOAQtUIN COUNTY EWIRnWENITAL 14HAti.Tri DRPAwr.4rf±NT as soot) as it is available anti lit lhe/,anit tC� cN� <br />provided to me or my representative. F/V O <br />TYPE of SERV1oE REQUESTED: <br />COMMENTS: <br />Diesel <br />(2111115) Replace relay <br />Fps <br />Evr <br />AOoEPTet)BY' .5 �� ,5 <br />EMPLOYEE i1: <br />DATE: 00 � — <br />AssiGNED T0: IL.7Aej <br />EMPLOYEE E #; <br />DATE: \ r <br />Date Service Completed (if already completed): <br />SERVICE CODE: X <br />it: : eZj�� <br />Fee Amount: O Arnount POW780,00 <br />Payment Date <br />Payment Type �� I olce <br />Ch k 63017 <br />Received By: <br />EHD 48.02.025 d3� / ( SR FORM (Golden trod) <br />REVISED 11/17/2403 <br />