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, 1-126-1998 10-21At' FRCM • • P. 2 <br /> w <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID 4 SERVIIeC�E RE.QEIEST y <br /> Mini Mart <br /> V <br /> BILUNG PARTY 0 <br /> flLVNER/OPERATOR <br /> Paul Sidhu <br /> FAaurrNME <br /> Waterloo Food & Fuel <br /> S"AMIZESS <br /> 3032 mm.4 4e, I Waterloo Rte-. <br /> Mailing Address (B Differ-int from Site A,ddrees <br /> 3032 E. Waterloo Road <br /> STATE <br /> R"tockton CA95205 <br /> PHONE#1 eR APN# LAto Use APPtxATM4 3 <br /> 209-466-5816 <br /> PHONE$2 tDta B(1$otxTittcr Low"Coos <br /> COVIUCTOR I SERVICra REQUESTQR <br /> REdtIFsrOR 8lurro Palm <br /> Keith A. Tallia <br /> Busines NMti PRONE$ <br /> Oil Equipment Service 09-754-1808 <br /> MAILING ADDROS FAX <br /> P.O. Box 950 R09-754-5726 <br /> CRT San Andreas STATE CA 7-P 95249 <br /> BILLING ACKNOWLEDrieft"R:I.N undorsgned PmPedy or busuress owner,operator or alltha med agent of same,admamedpe+hat an site andior Mclett spy:fc <br /> ROJO HEALTH SOWM EW1R%W0T WEALTH DfA m►an+iy Orargos atSooBaad with this pmr-d or acvity wit be hided 10 me or my huslness as&nMed on It t tram. <br /> I also cer*that 1 pmpa >lication and a wM be done in a=rdw tx witlt ed SMJOA"C UPM Gec&tce Codes.Start'Q*STATE and <br /> 11 /16/98 <br /> AMCANTSIGNATtNZE 6 t DATtt <br /> eicvF <br /> a a <br /> PRCPERTY/8 �aWN" c t�v,YCt►.1MhNAM Q ort�AurKFsMAWC X1.P�r Ps; <br /> CAPPEKMOSnOt Ole P,rrtrr god ctad"bNom to x1va b ngww Title <br /> AUTHORIZATION TO When WpiMbis,L the omw or operator o{Bre property located at the ttbare aRe address,hereby a�lhO ize ne r+�sa of <br /> any and aA results,geotedmical data andicr emtkwr1wMttW asBW3ffwd irdannotbn to the$.Wi jNwa Rt Cou►rrr PUeW Ht&j%SE vtct's EWRON ITAL Htv1Llw QMsoli as soon <br /> **ii it avafabfo ane at the soros dyne R a pMMM 0 me Or my rapseserrMUve <br /> 'fYPEOFSERvicEREclimvn: Replace underground motor fuel storage tanks <br /> t.orrttErTs: . PAYM IE NT <br /> RECEIVED <br /> DEC "11998 <br /> SAN JOAQUIN COUNTY <br /> PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> INSPECTOasSIGNATURE: } CONTRACTOR'SSIGHAMM: <br /> APPRosr: E 1t4tAYYEE DATE <br /> vm <br /> ASSIONEDTa S EtWLOYgiff: DOD DATE:— <br /> Date Service Completed (f#a Ntiy coatpl S Iv1rF Ct>r:e - .' P f E. 42 <br /> Fee Amount: l Amount Paid Payment Datta <br /> Payment Type Invoice 0 Check d Received By. <br />