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To: Elena Manzo Page 6 of 13 2018-09-05 16:47:04(GMT) 17076380484 From: Nucleus Pump Services <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Gas Station <br /> OWNER/OPERATOR <br /> Colonial Energy, 11C. CHECK ifBILLING ADDRESS❑ <br /> FACILITY NAME Power Mart <br /> SITE ADDRESS 1434 W Yosemite Ave Manteca 95337 <br /> Street Number <br /> HOME or MAILING ADDRESS (tf Different from Site Address) 2860 N Santiago Blvd, <br /> Street Number Strftt Name <br /> CITY Orange, STATE CA zip 92867 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (714)761-5426 x295 <br /> PHONE ftp EXT. SOS DISTRICT LOCATION CODE <br /> ( I <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR Ronnie Lewis <br /> CHECK if BIWNG ADDRESS <br /> BUSINESS NAME Nucleus Pump Services <br /> PHONE# ExT. <br /> 916 382-4761 <br /> HOME or MAILING ADDRESS 601 1st Ave..Suite B FAx# <br /> ( 707 )638-0484 <br /> CITY Sacramento STATE CA ZIP 95818 <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project Speck ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated With this project or <br /> activity will be billed to me or my business as identified on this form. <br /> I also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: Q..1--�- � DATE: 8/16/18 <br /> PROPERTY I BUSINESS OWNER❑ OPERATOR I MANAGER ❑ OTHER AUTHORIZED AGENT if Contractor <br /> If APPLICANT IS not the BILLING PARTY,proof of authorization to sign is required Title <br /> AUTHORIZATION TO RtLEASg !NFORMATION: When applicable, I, the owner or operator of the property located at the above <br /> siteaddress, hereby authorize the.release of any and all results,geotechnical data and/or environmentallsite assessment information <br /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the sal,tiLTiB its44X <br /> my representative. r _<.,:{ AT Lj <br /> TYPE OF SERviCE REQUESTED: <br /> COMMENTS: <br /> ENVIRONMENTAL <br /> HEALTH n.PARTMEN <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE M DATE: <br /> Date Service Completed (it already completed): SERVICE CODE: P/E: <br /> Fee Amount: Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07117/08 <br />