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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 f"O /2 � � � SQ bD 0 2 <br /> OWNER / OPERATOR GHULAM ALI <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAMEA&A GAS & FOOD MART <br /> SITE ADDRESS 1330 EAST YOSEMITE AVENUE MANTECA 95336 <br /> Street Number Direction Street Name c1tv 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 /> ( 510 ) 396-5560 22 �S 2j <br /> PHONE #2 EXT, BOS DISTRIO� LOCATIOON CODE <br /> ( 209 ) 825-0332 �—Jy <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR TONY MEHROKE CHECK if BILLING ADDRESS ® <br /> BUSINESS NAME TANK-TIGHT SYSTEMS , INC . PHONE # 667-689EXT. <br /> 916 1 <br /> HOME or MAILING ADDRESS FAX # <br /> 8515 WATERMAN ROAD ( ) <br /> CITY ELK GROVE STATE CA ZIP 95624 <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 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 : o y\'2! ��o � �� DATE : 9/27/2021 <br /> PROPERTY / BUSINESS OWNER ❑ OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT ® CONTRACTOR <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 /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the same time It Is provided t0 me Or <br /> my representative . <br /> TYPE OF SERVICE REQUESTED : Sr � FYI t� PICS <br /> COMMENTS : CC' V <br /> SAN SEP 2 20? <br /> Oq <br /> HEO' k %rl ONMEcou Y <br /> ACCEPTED BY: �v�0� �j ) EMPLOYEE # : DATE : 1742 <br /> T E <br /> ASSIGNED TO : `/ i AT 0 L� EMPLOYEE # : DATE : q / z/ <br /> Date Service Completed ( if already completed) : SERVICE CODE: 41,f, .2J P 1 E : ,4 <br /> Fee Amount: J 2 Ot Amount Paid Payment Date 4?17 <br /> Payment Type Invoice # Check # �3z b � 7 ReceIVed By : <br /> EHD 48-02-025 SR FORM (Golden Rod) <br /> 07/ 17/08 <br />