Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />SERVICE REQUEST # <br />Convience Store <br />FA OCA 0q <br />3 <br />OWNER I OPERATOR <br />CHECK If <br />o <br />BILLING ADDRESS <br />FAVvyy NAME <br />h U <br />Fast N Esv #116 <br />1 989.5 Railroad Ave. <br />SITE ADDRESS <br />( 209) 537-9398 <br />C)r6eres <br />STATS CA. ZIP 95307 <br />DATE: 30 <br />AssfoNaoTo: <br />1399 S(loal mtt�r <br />a <br />E. YosemitegAe e. a <br />Date SerylcoCompleted (if alreadycompteted): <br />Mante a <br />9z�53d6 <br />NOME or MAILMo AI onu of Different from Site Address) <br />Fee Amount: 3 ® <br />mount Pa <br />ShaoE a he <br />Payment Date <br />Strcol No ma <br />CITY <br />to [ce # <br />STATE zip <br />PHONE #i Exr. <br />APN N <br />LAND U86 APPLICATION # <br />PHONE #2 8xr. <br />t l <br />SOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR/ SERVICE REQUESTOR <br />REQUESTOR <br />Garber <br />CxeCK If BII.4INo ADDRESSI-moi <br />BusiNEse NAME <br />3 <br />_ <br />FNoNE # a't <br />Company <br />o <br />7-9396 <br />Ho&in Or MAILINo ADDRESS <br />h U <br />FAX# <br />1 989.5 Railroad Ave. <br />( 209) 537-9398 <br />C)r6eres <br />STATS CA. ZIP 95307 <br />BILLING ACKNOWLEDGEMENT: I, the undersigned properh' or bustnes.s owner, opel•aior or authorized I gent eP snrne, <br />noknowledgo that all site and/or prgjeet speoirlO ENv1RONNiVNTAL JhAt.TiT DEPARTMENT hourly Charges associated with this prt ject <br />or activity will be Filled to me or my business as identified on this form. <br />I Also certify !lint I have prepared this apphoation and that thea work to be performed will bo done in necordnnoo with all SAN JO.wtaNl <br />COUNTY OrdiNlllrcc' Corlea, S'llrlJdaJc s, S'PATL' and F FDERAI, Ilnvs, <br />APPLICANT'S SIGNATUR'E! r /L. t— DA rt;; _ - ` 0 `f �� <br />PROPERTY/ B1181INK&SOWNF.RE3 OPERATOR/Mi is AGFR OTHERAvTHOnizKu t('+r:N. _ T® ipryi Agent <br />1f,4111 1CRN1' Is Hot the R/UINO N/rr') proof of audrorkadbit to ,sign Is required i'hl e <br />AUTHORIZATION TO RELEASE INFORMATION. When applicable, I, the nwner or operator of the prnperty loomed III the <br />ahovo, site n(hiress, heroby nuthorizo the release or any and all results, geotechnical data and/or cnvimnmentallsite nswssment <br />information to the SAN JOAQVIN COIINTY T,MIIRou\4RxrrrAL HBALTII DRPAR'r..VFNT as soon as it is avnilablo and tet the salve time it k <br />provided to mo or my representative. NYA.^ <br />TYPE OF SERAoE REQUESTED: <br />CF/t/ r <br />COMMENTS: <br />3 <br />(712115) Replace Veeder Root annular sensor L-8 <br />o <br />h U <br />AOCEATED BY: <br />EtaPLOYEE #: <br />DATE: 30 <br />AssfoNaoTo: <br />EMPrAYf:r0; <br />DATE: 613 <br />Date SerylcoCompleted (if alreadycompteted): <br />SfRVICECODE: <br />PIE: <br />Fee Amount: 3 ® <br />mount Pa <br />Fd pD <br />Payment Date <br />36 <br />Payment Typ <br />to [ce # <br />Che # Q30/ 7 <br />Recelved By:ZT <br />END 48-02.026 SR FORIA (Golden Rod) <br />REVISED 11/17/2003 <br />