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02-12-09;03,51PM;TOWN & C NTRY CONTRACTORS916-636-9507 # 2/ 2 <br /> C,L,1„4/LrJ C,' ,�,�.�„� �,KJa4p4 0 G"�VIRUIYIYICIYIHL P1 ; PMl7G YJL/UL <br /> SAN JOAQUIN COUN'T'Y ENVIRONI►7 ZNTAL HEALTH.DEPARTMENT <br /> SERWCE RiQUEST <br /> Type of Business or Property �A—ciCITy Ib# SERVICE REQUEST# <br /> GASOLINE DISPENSINC FACILITY <br /> OWNER/OPERATOR <br /> SANJAY BIRLA CHECK IfBILuNaAeQRratt12 <br /> FB CRY & MARKET <br /> SITEADDRESS y,T 11TH STREET TRACY 95376 <br /> 515 Stmt umber t y. <br /> Ca e <br /> I"IOMEOrMAILINUADDRE85 (If Diffarentfrom Site Addra.rs) <br /> t'moPt Number vest Marne <br /> Oily STATE Z1P <br /> RHONE#1 EXT. APN# PBCOS <br /> No USE APPLICATION# <br /> (510) 414--5390 233-090231 <br /> PHONO2 E>T DIMICT LocATIQF�CCoe <br /> CONTRACTOR/SERVICE REQUESTOR � <br /> RI�aUE$TOR X <br /> LUCY SII,VAS-THOMAS CMWK if MLURG-AMMIJ,❑ <br /> BU51NE5 ME PHONE# Im <br /> TOWN & CO=RY CONTRACTORS, -INC. .911 636-9500 <br /> How or MAILING ADDRESS FAX# <br /> 3181 LUYUNG DRIVE STE A (915 )636-9507 <br /> C'TYRANCHO CORDOVA, CA STATE CA &jP 95742 <br /> MUM ACKNOVRLEIDGELMENT: 1, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH lar-MAMMENT hourly charges associated with this project <br /> or activity will be billed to me or my business as identified on this farm_ <br /> 111,39 oerti.fy that I 1 ave prepared this application and that the work to be performed will he done in accordance with all SAN JoAQarN <br /> A�UP'L <br /> 'TYOrdinance Codes,Standards, an EDERA laws.ICANT'S SIGN RATE:_r-�/�I I—0 <br /> PROMW J]BUSUMS OWTVER �PI:RA TOR 1 MANAGER C3 OTHER AtMiORIZED AGENT CONTRACTOR <br /> IfAFPLICANT is not the,BILLING P.4)z proof of a nfkori2afipn Jd sign is required rlrle <br /> AUTRORILATI,ON TO RELEASE INTORMATION:When applicable,I,the owner or operator of the property Iocated at the <br /> above site address, hereby wthori= the release of any and all results, geotechnical data and/or environmentaUsite assessment <br /> information to the SAN JOAQUIN COUNTY ENviRONMCNTAL HrkALTJJ IXPARTMENT aq,3909 as it i5 avai 1a�t and at the same time it is <br /> provided to me or my representative. N� <br /> TYPE OF SERVICE PJQOESTED: P c�� ®O <br /> CDMMENT6; GGJP <br /> ACCEPTED BY: ( (1 Ug t e 4 EMPLOYEE#. dour!?: <br /> Q� r p c <br /> AssioNED To: EMPLOYEE M J �+I DATE: /2 <br /> Data Service Compl®ted (if ilready completed): SERVICE CODA: r qol> P J E: 0 <br /> Fee Amount: i o Amount PaidS Poymmnt Date al 1'Z-/U <br /> Payment Type Invoice# Check# Recelved By-, <br /> RHD 48-02'025 SR FORM(Golden Rod) <br /> ftEV15E0 11!17/2003 <br />