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SA, N- JOAQUD COL-NIT EN IRONN ENTAL HEALTH DE;P_A RTS WN-1- <br /> _ _ SERVACE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Gas Station!Convenience Store..'Car Wash FA000782.1 5 R 0P S 5 8 77 4 <br /> OwIVER/OPERATOR <br /> Blaekhawk Management Group, LLC C�-ccg It 11&-Uhla A=rkEaso <br /> j F&zcrnNAw- Proposed ARCO &AMIRA <br /> SfTEAm;mss 7500 W Eleventh Street j Tracy 95304 <br /> MmttNwrber Dircctfon I *vred Na-Mi 2:n Codr <br /> HONE or fdatuNG ADMS75 Or Different ttrom Site Address; 2605 Camino Tassajara Lane, #1582 E <br /> ffi.not Nun"r I U wwt N,errr I <br /> crry Danville ST CA ZIP 94526 f <br /> Pit)N_M Er' APht250-150-16, 17, 18 L OLID —PPPLIZA:o�[9 <br /> (925)548-7910 PA-2100275 <br /> D4: 92 BOS DtsTP-.-T LocAnou Cccc <br /> ( 1 <br /> (,ON'T'RACTOR ! SERVICE REQUESTOR <br /> REQUESTER Edear Hlckallah CJercK if St ha AnoRFUZ <br /> B:ls•v=ss NAME Pi;cnE;£ E" <br /> Blackhativk Management Gaup, LLC (925 E- <br /> 1548-7910 <br /> H-=E or MA.P_iNo ADDRESS FAX Z <br /> 2EC5 Carinr,-;gz,.'ara'-ane•*11SA-2 + ; <br /> C'TM Danvi'le SrCA ZIP 94526 <br /> Rlt t Nq AC1CigGIZEDrEt+[ENT: T, ttc tindclYigrtcd properij o' business owner, operator of 2uthori?*4 agent of same, <br /> azknmvIed.z*x all size -iwj-'orprej;-ct SxCifi:��;(=;c)a1✓=�?�:.'sii. i:rL T)�i-Ax-jNwNrhmirh eh rFcs tlssnc 1Tcd c•ith_iis prcjcct <br /> or az N—itl will he billed to nae of mT -basinesti zs ideui:ied u tis fuItLL <br /> T also ce-t fti (111!1 lave prcpa.-cd tans application snd thrr:x work m h:pc:fomicd-AU be dcm'n seen:ducc n T°1 all S ,'IC:•rQt <br /> C'oi_=.Y Orcir=ce Canes a 51 si':ane F=.r=::�,�;.1V s� <br /> APPLICANT'S SIGNATURE: _ }` <br /> PRoarie-v;31 VNI;.i O.•• 1J_'J O r;1i t.ox:NLix:c:x O :txA.zuoxtzEo Ae_,= -- <br /> :. i 7:(1:i1:r,�__ `''_ �,:_?T'.Frn(f of aidharlTallon to JWA 4 rejuired rifle <br /> VIMORIZUT1ON TO RELEASE INFORMATION: %V, xn applick.Tc, I,thz owner or operaror of the properr lccztcc at'.x <br /> chDt'c 5ItC address, 1x:Cl`\' ill4 JR7.0 (l1C ICIC?.$C 4f arn" 1rz :11. I'C$i:.TS, dam and:br Crt irnrrrxT_t3_si C ass---sMC3_ <br /> i lfo>z.1t D�tc ih= 5:� J4..J T COt�::=�• o�1tC�'.�t H= De?.•.k^.tG\7 as soon as t is at ai:.—:-lz and at th-=e Lmr,-is;S <br /> provided tD mC or mpr`scr_tativc. <br /> PAYMFPJ <br /> TYPE CFSM10ER=r._EsrEe:Review o`Soil Sui;ab'iliy.,Nitrate Loadire Study RECENED <br /> O i;r D 5 2022 <br /> UL I I U 2022 SAN JQAC:,:a,Cc:;%TY <br /> ENMRONVZNTA� <br /> i HEA-TnDE?ART-V.-vT <br /> ENVIRONMENTAL HEALTH <br /> AccEPT=7 By: Est-_oyu 1 - QAr,-: -ta S ZZ' <br /> ASS=--D TO: (rR0.�fi• t'��LS �>?_ori _: u t i S DntE <br /> Date Service Completed fit already eornpleted): srwc-001x: Z- P:E.�(a p Z <br /> Fee Amount: (� Amount Paid Payment Dem ;'r^ <br /> ment Type ;^ j � 1 Invoice Check T f '�i }�� Recxived Br: <br /> Pay <br /> EHE A&Z2-:25 SR CCRV(3c!de-Roe, <br /> P.EVISED <br />