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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # SERVICE REQ <br /> IL11 2 <br /> C - Store 1 48(3561 � towadOOZ <br /> OWNER / OPERATOR <br /> CHECK If BILLING ADDRESS ® <br /> Balwinder Singh <br /> FACILRY NAME <br /> Escalon Mini Mart <br /> SITE ADDRESS <br /> 1097Yosemite Ave . Escalon <br /> Street redlonCity Zip Codo <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> SlreetNumher SI eotNamo <br /> i <br /> CITY STATE Z:IP <br /> i <br /> `HONE III Exr. APN # 1 a �, LAND USE APPLICATION /I <br /> t i <br /> PHONE ill Exit BOS DISTRICT )� { , LOCATICO E <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK if BILLING AODRE39 <br /> Bonnie Garber <br /> BUSINESS NAME PHONE 0 EXT , <br /> Donlee Pump Company 537-t9396 <br /> HOME or MAILING ADDRESS FAx t# <br /> 2825 Railroad Ave . ( 209) 537-9398 <br /> CITY STATE ZIP <br /> Cares , CA . , 0.9307 <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 /> 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 : S DATE ; <br /> PROPERTY BUSINESS OWNER 1:1 OPERATOR / 4N GER 11OTHER AUTHORIZED AGENT 0 <br /> If APPLICANT Is not the BILLING PARTY, proof of authorization to slydn Is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION : When applicable , I , the owner or operator of the property located at thea ; MENT <br /> site address , hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment Infor EIVED <br /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as Soon as It is available and at the Same time It is provided toVr�@ ,Or <br /> my representative , �l V l 2021 <br /> TYPE OF SERVICE REQUESTED: It t I%C—�/ ' � ' SAN JOAC uiNCotINTX <br /> NMENTAL ` <br /> HEALTH E PPARTME�M <br /> COh1h1ENTSa <br /> Replace ULS sensor in UDC 7/8 due to failed test . Q � <br /> wow- <br /> P"740 <br /> ACCEPTED BY: r �F� (J� EMPLOYEE It : DATE : <br /> ASSIGNED TO : � 17 2 XU <br /> EMPLOYEE tI : DATE: <br /> Date Service Completed (7f already completed) : 2y ,Zi SERwcECoDE; 05 <br /> _ t' ! E ;✓ % <br /> Fee Amount : 5c �� 70t" - Amount Paid ( Z Payment Date <br /> Payment Type � +S Invoice # Check # %j 5 07 / D C, Received By : <br /> I <br /> EHD 48-02-025 SR FORM (Golden Rod) <br /> 07/17/08 <br />