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i <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Typo of 9usinese or Property FACILIT ID 11 88RVIC8 REQUEST a <br /> Fuel dispensing station 06 00 t,q 2l Cj <br /> . I <br /> OWN900Pf"RATOR rp CHICK II I31 UNo Do <br /> FAmny NAIR # <br /> Kwik Sery Eaoalon <br /> SITE ADDREOS Jaokeon Ave <br /> 2601 Esoalon <br /> stroplNumber IrealIgno cit <br /> FWil er MAILING ADDRE88 (If Di feront front site Address) j <br /> LA) a �V �r 8 ao u balroal Hong <br /> CITY 6TA7 zip <br /> PHONE 1 E0' APNN LAND Use APPLICATION 0 <br /> PRONG R2 6xT, BOe DIsiRIOT LaQATION CODs <br /> CONTRACTOR / SERVICE REQUINSTOR. <br /> Raques'roR <br /> 8Z Maintenance Ctiffrifl( PILLINgAounesell <br /> BualNEas NAMEgz Maintenance NONE # e>,T. <br /> 0161 8 <br /> HOM2 or MAILING AoPREss FAX A <br /> PO Box 933 <br /> CITY W Saoramento STATE zip t <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all elle and/or project speoifiO ENVIRONMENTAL HEALTH DaPAnTMENT hourly charges assoolaled 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 appltcallon and that the work to be perforated will be done In accordance with all BAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards, TAT and FEDERAL laws, <br /> APPLICANT'S SIGNATUR15i !� DAw 91 f ;L I <br /> x ItOPERTY I BUSINESS OWNER a 0 ERATOR I MANAGER d OTHen AuTHORIZ0D AoENr ❑ <br /> If ANPLioANT is not the SiLtlNo PARTY, proof of suthorizatlon to sign Is required Title <br /> AUT80RIZATION TO RBLE,ASE IN RM(, MA710NI Whan applicable, I, the owner or operator of the property located at the above � <br /> site addrass, hereby authorize the release of any and all results, geotechnical data and/or environmental/elle assessment Informatlon <br /> to the BAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as 800n as It Is available and at the same time It Is provid to m i or <br /> my representative. ��77 <br /> TYPE op SwimREQUImeu; A '� S T - � ' ( <br /> COMMENTS: <br /> Remove (3) drop tubes that measured over 95% and are out of regulation , Sep <br /> Build and Install (3) drop tubes according to regulation specs . <br /> HE NVR Quov <br /> 4 � Y& /vMFCoo Ty <br /> AOoEPTCo (3Y, OC \/ UMPLOYEE II; DATE' <br /> AssloNapTo, `� � � �� ? EMPLOYEE Of DATIq Z <br /> Uate Servloo completed (if already completed); Sf;RVICGCODR, G����Gf' Ole! <br /> 1 <br /> Fee Amount , Fq t�l�j o a Amount Pa C , v Payment pate <br /> Payment Typo (?PLda Invoice # Ghack # Z 1 enol ed By ; <br /> I <br /> f <br /> EHD 48.02-026 eR FORM (aotden Rod) <br /> I <br /> 07117!08 <br />