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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # SERVICE REQUEST # <br />Convience Store <br />0 a bO/ C> q11 <br />1 <br />OWNER / OPERATOR <br />CHUCK <br />PHONE N ax' <br />If BIL LINO ADDRESSLI <br />FACILITY NAME <br />537-9396 <br />Fast N Esy #116 <br />SITE ADDRESS <br />98915 Rallrond Ave. <br />To: <br />Ad <br />( 209) 537-9398 <br />CiZeres <br />STATE CA. ZIP 95307 <br />1399 lilsiel umber <br />SERVICE CODE: t E: <br />E. Yosemite Ave. a <br />Street N <br />Mantes a <br />9z�536 <br />HOME Or MAILING ADoues (it Different from Site Address) <br />Ch k # <br />d3��'1 l <br />Recel ad BY: <br />SlroaENumber <br />svoolRama <br />CITY <br />STATE 21P <br />PHONE 01 T <br />t 1 <br />APN # <br />L.AiID USE APPLICATION # _ <br />PHONE 62 ser• <br />t 1 <br />Bos DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />CF- �F T <br />Die Garber <br />cxr cx ll.t if BINo AookassBon� <br />Susmusa NAME <br />PHONE N ax' <br />narilea Pump Company <br />537-9396 <br />Honor Or MAILING ADDRESS <br />FAX <br />98915 Rallrond Ave. <br />To: <br />Ad <br />( 209) 537-9398 <br />CiZeres <br />STATE CA. ZIP 95307 <br />1-31LLING ACKNOWLEDGEMENT: I, the undersigned proporty or business owner, operator or authorized agent of snore. <br />noknowledgo tient all site and/or project Speeirle ENVIRONTOENTAI,1F11W.TIr Dm)ARTAIENT hourly chorgus associnted with this proiect <br />or notivity will be billed to me or my huMnerla as identified on Ihis form. <br />1 also certify that I have prepared this applioation and that the Work to be performed will he dorso in accordance with all SAN JO,x()t l� <br />COUNTY 0U1h)I711ce Codes, .SYrrrularcls, >S't',%TL and FEDERAT, laws, <br />APPLICANT'S SIGNATURE r '� D,vpF;; 6 <br />PROPERTY 1111Si,\F.68 OWNY,R❑ OPHRATO / A ANSGFR ❑ 0,rtm tAirmont7,kosPryoce Agent <br />ffAmve,4N1' is nol the 13ituma Pwrrt, proof of authorization to ,sign 1s required 7Yrte <br />AuTHQBIZATXON TO RELEASE INFORMATION. When applienble, I, rhe nwr'rer or operator or the pr'operh' located III the <br />above site address, hereby authorize tho roloase of any and all results, geotechnical dnin Dud/or environmental/site assessment <br />infortllatietl to the SAN JOAQUiN C0V'4TYR.M1IP0NN4RX1TAL 14EAlan DF.PAR'rx4rNT as soon ns it is ilvnlllible and lit Ills: "alllc Illlle it Is - <br />provided to mo or my rcpresontotive. A <br />D AYA.,r.. <br />TYPE OF SERVICE REQUESTED: <br />CF- �F T <br />COMMENTS: <br />(1/7/16) Replace 87 Turbine Red Jacket LLD due to failed testing. <br />3 <br />ACOEP7E11BY: Cr)� p <br />DATE:Assicmec <br />To: <br />Ad <br />EEMPLOYEEM <br />s #: <br />DATE: A <br />Date Service Completed (if already completed): l _ �l <br />SERVICE CODE: t E: <br />Fee Amount: 3� 3.9U , Amount Pa y6,d/j <br />Payment Date <br />Payment Type <br />Invoice# <br />Ch k # <br />d3��'1 l <br />Recel ad BY: <br />EHD 0-02.026 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />