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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACIUTY ID/ SERVICE REQUESTS <br /> Truck Yard <br /> OWNER I OPERATOR CNefir N BIwrW ADaREea® <br /> FAaurY NAME Super Store <br /> SrIEADDMs 16888 S• McKinley LGIN <br /> athrop 95330 <br /> HOME or MAILING AnDaEsse.Wr(11 Different from She Address) Sven N� <br /> BeMt Nwv <br /> CITY STATE LP <br /> PNONE/1 En' APNA LANOUWAPPUCAMONi <br /> ( 1 <br /> PHONEl2 B09 DRTRICT L1lLATIDN CODE <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR CHErx n DwNo AcoREsa❑ <br /> Greg Kaiser <br /> BUSINEss NAME PHart/ <br /> Kaiser Commercial Petroleum 1209 401-2379 <br /> HOME or NlmuNO ADDRESS Fut <br /> PO Box 1058 ( ) <br /> Cm Linden STATE CA zip 95236 <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of name, <br /> acknowledge that all site end/or Protect specific ENVIRONMENTAL HE TH DEPARTMENT hourly charges associated with this project or <br /> act"will be blued to me or my businesses 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 wcDrdance with all SAN JOAQUIN <br /> \/COUNTY OrdiRerwe Codas,Standards,STATE and FEDERAL laws <br /> X APPLICANTS SIGNATURE:,— --: �� DATE: 1�0-/�Z/ —�•( <br /> PROPERTY/BUSWEa6 OMER13 oPEAATOR1MrMOSR Or, OTHeRtAUTHORIzEn AOENi <br /> 17AppuawT/s not rhe B&LUNr9 PARTY.proof orauthorfzatfon to sign is required Tule <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable, I,the owner or operator of the property located at the above <br /> sits address,hereby authorize the release of any and all results,geotechnical date and/or environmentailege assessment information <br /> t0 the SAN JOAQUIN COUNTY EN VIRONMENrA HEALTH DEPARTMENT 26 Boon as it is available and at the same time it is provided to me or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: <br /> ca mm, Cut out existing direct buryspill bucket on tank#1, replace like for like with OPW 2100 <br /> Series spill bucket. After inspection and verified,back fill and pour concrete. <br /> AcDEPTer,BY: EMPLOYEE M DATE: <br /> AeeIONED To: EMPLOYEE N: DATE <br /> Data Service Completed (If already cemplelod): SEAWCECooE: PIE: <br /> Fee Amount: Amount Pald Payment Date <br /> Payment Type Invoice If Check# Reoeivetl ey: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />