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I: <br /> SERVICE REo0E5T *4�r Property FACILfTY ID% <br /> TATION SERVICE REQUEST:P <br /> �;NERIAY, INC. SUINGPAatt❑ <br /> AY FUEL CENTER #1769 <br /> 2808 .: :9vwawwwr Rncsn COUNTRY CLUB s.wea.» BC <br /> Wiling Address (If Different from Site Addresa) ' <br /> 5918 STONERIDGE MALL ROAD <br /> Cth STATE 2w <br /> PLEASANZCJN <br /> RE%1 CA 94558 <br /> PfiOW. APN# LANOUSEAPP=MN% <br /> � 2n 467-3000 121-181-020 <br /> PNI ONE%2 On. BOS DIStIUCT L.OutIpn COOE <br /> CONTRACTOR I SERME MgUESTOR <br /> REj1UEnOR <br /> Bt✓,SWE45 RNE 1 PHONEAt eR, <br /> MA, <br /> AOORESS "tom t <br /> !370 \pf>N t� FAxB �p <br /> C ' '�^S'�\4�t�JT ZJt�j- <br /> L.JV\S b$\✓�v STATE e-A 2JP 1 ✓R/ <br /> BI IN ACKNOWLEDGEMERT:I.Ne unomigned pmperty or bwinesa owner,operator or aurhortrad agent of tams acknowledge Nat ad Six andfor project spec& <br /> Pvuc MFAtiX SFJivrJ=s EmvlaNufxr u NfrETN lMkspN nouM Clarges assocated vfM No POjeaor ac"wie be billed iD me ormy business as Cmafied m M bm <br /> to 0 mrofy Nal I haye prepared thappimbon and a wont 0 be pertomwd will be done in a0zmance WM t%SAN JOAOUW Cawrr <br /> FEOEPAL laws. Oldinena Coda.SfandWa,STATE and <br /> — LJKANrsc"" — ACC— ' -7 DATE: 2/21/01 <br /> P,aPPOtTyIIBusWEsc 0 TOR)MANAGER ❑ On�RAurKil,=AG6w M ,TEFF CEE — F P A <br /> rAwacAwr<,ae,t Banc Pwm.Pmerer«rdrertratlon ea Alpr braauiwd rill. <br /> AUTHORIZATION TO R EASE INFORMATION:When appkabw L the awl mapermr of the property located at the above silo addmat.hereby euenorvA are mWm of <br /> aqy and an reaulb.geolechn,al dam aMllar envhonnnenaesae at3nivnenr 4nturnadon b ew SAN JOAOJW CwNn Poetic HEALT SERvKES EN RDD ALHEAL:N ONtw)"u soon <br /> rile a it"4ote and at Ne same eme A is prwided b me or my repnpermdve. <br /> Typf OF SERVICE RfGUFSTEU: I I / '� �•,. f _ n I) �w <br /> Cf�MaIEJrrS; <br /> � FACYM tV-i <br /> RECEIVED <br /> i <br /> FED 2 2 2001 <br /> I <br /> SAN JOAOUIN COUNTY <br /> I� PUBLIC HEALTH SERVICES <br /> I' FNVIRONMFNTA( HFAI TH DIVISION <br /> tNSPECroR:S SIGNATURE: CONiAAG1OlY3 SIGNATURE: <br /> ,PROVFD'�9y: EHPLOMt. <br /> ASSIGNEE iO: f&wLOTEE*: DATE <br /> l <br /> Date Service Completed (if a(readyCOMPleted): SERyI¢Cooe ,:0 I PIE. �D-3 .. <br /> Fite Arnolint Amount Paid Payment Date <br /> Payment Type Invoice 0 Check 0 - Recelved BI,_ <br /> PAMEN] <br /> RECEIVED <br /> MAR 14 <br /> 2001 TOTAL P.11 <br /> -� II <br /> 1..4 SAN JOAQUiN COUNTY <br /> { <br /> PUBLICO HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH' <br />