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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # SERVICE REQUEST # <br /> gas station ? Vo Q1 C33 Ile <br /> OWNER / OPERATOR <br /> Monica Farhat CHECK If BILLING ADDRESS <br /> FACILITY NAME Manteca Cruisers <br /> SITE ADDRESS 1137 W Lathrop Rd <br /> Str et Number nre em CI <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number treat MAMA <br /> CITY STATE zip <br /> PHONE #1 EXT. APN # LAND USE APPLICATION # <br /> PHONE #2 EXT. BOS DISTRICT LOCATION CODE <br /> ( 1 <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR Marty Weithman CHECK If BILLING ADDRESS LI <br /> BUSINESS NAME PHONE # ExT. <br /> Service Station Systems , Inc. 408 213-6038 <br /> HOME or MAILING ADDRESS FAx # <br /> 680 Quinn Ave <br /> (408 ) 213-6026 <br /> CITY San Jose STATE CA ZIP 95112 <br /> BILLING ACKNOWLEDGEMENT: 1 , the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project <br /> or 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 iFEDERAL laws . <br /> APPLICANT' S SIGNATURE *V MA < <br /> k L- y vw L � DATE: 3/6/2019 <br /> PROPERT)A / BUSINESS OWNER OPERATOR / MANAGER ❑ OTHER AIITHORIzEDAGENT O✓ Compliance Officer <br /> IfAPPLICANT is not the BILLING PARTY, proof of authorization to sign is required Tire <br /> AUTHORIZATION TO RELEASE INFO M>�i ATION : When applicable, I , the owner or operator of the property located at the <br /> above site address , hereby authorize the release of any and all results , geotechnical data and/or environmental/site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative . NT <br /> TYPE OF SERVICE REQUESTED : UST inspection E 11 f E ® <br /> COMMENTS : <br /> MAR 11 2019 <br /> SAN JOAQUIN ,BOUNTY <br /> ENVIRONM NTAL <br /> HEALTH DEPA TMENT <br /> ACCEPTED BY: EEmPL=OYEE <br /> YEE #: O o DATE: <br /> ASSIGNED TO : DATE: <br /> Date Service Completed ( if already completed ) : SERVICE CODE : PIE : <br /> Fee Amount: Amount Paid 4 . 6o Payment Date 3 � � `Gl <br /> Payment Type Invoice # Check # Received By : <br /> EHD 4842-025 SR FORM (Golden Rod) <br /> REVISED 11 /17/2003 <br />