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SAN JOAQUIN COUNTY ENVIRONMENTAL , HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # SERVICE REQUEST # <br /> Gasoline US / J0 �7 <br /> 1 , " <br /> OWNER / OPERATOR CHECK If BILLING ADDRESS ❑ <br /> Abe <br /> FACILITY NAME <br /> Gas Depot # 2 <br /> SITEADDRESS East Yosemite Boulevard Manteca 95336 <br /> 1330 Street Number Direction Street Name City Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE #1 ExT• APN # LAND USE APPLICATION # <br /> PHONE #2 ExT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR CHECK If BILLING G ADDRESS <br /> O <br /> 9 Young Doug <br /> 1 <br /> BUSINESS NAME PHONE # Exr. <br /> 661 631 -3870 <br /> Confidence UST Services <br /> HOME or MAILING ADDRESS FAx # 587-9758 <br /> 16250 Meacham Road ( 661 ) <br /> CITY STATE ZIP <br /> Bakersfield <br /> BILLING ACKNOWLEDGEMENT: I , 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 or <br /> activity will be billed to me or my business as identified on this form , <br /> also certify that Ihave prep ed this application and that the work to be performed will be done in accordance with all SAN JOAOUIN <br /> COUNTY Ordinance Codes, Sta ards, STATE and FED E L laws . <br /> APPLICANT' S SIGNATURE : h DATE : 6/24/2019 <br /> PROPERTY / BUSINESS OWNER ❑ OPERATOR I MANAGER ❑ OTHER AUTHORIZED AGENT ■❑ Permit Clerk <br /> If APPLICANT IS not the BILLING PARTY, proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION : When applicable , I , the owner or operator of the property located at the above <br /> site address , hereby authorize the release of any and all results , geotechnical data and/or environmental/site assessment information <br /> available and at the same time it is provided to me or <br /> AN JOA UIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as SOOn as It IS a P <br /> to the S Q <br /> my representative . Z -� `; jl , ; j (_' � � <br /> TYPE OF SERVICE REQUESTED : IN (6) GILBARCO ENCORE 500S DISPENSERS l �, �> � - �( <br /> COMMENTS : S .RECE' 3 ' <br /> EIVED <br /> JUL 2 4 2019 <br /> SAN JOAQUIN CO <br /> ACCEPTED BY: EMPLOYEE # : q r ' <br /> ASSIGNED TO : ✓✓✓���` ,j D EMPLOYEE # : 00 � DATE : _ <br /> Date Service Completed (if already completed) : SERVICE CODE: / iJ/ P I E: <br /> Fee Amount: 9 Amount Paid /�5 Payment Date <br /> Payment Type Invoice # Check # SSZ Received By : L01 �J <br /> Pa <br /> EHD 48-02-025 SR FORM (Golden Rod) <br /> 07/17/08 <br />