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• • MAM <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT OCT 12 2016 <br /> SERVICE REQUEST INVIIIIINE41 01 ALM <br /> Type of Business or Property FACILITY ID i SERVICE RL'Q��q�Ony, <br /> Truck Yard �(} �j9, S� 6a�1�o33 <br /> OWNER I OPERATOR <br /> LNEcxHBLumG gpQResg® <br /> FAcury NAME Super Store <br /> SDEADoilm 16888 1 S. McKinley Lathrop 95330 <br /> Mum <br /> HONE Or MAILING ADORM (If Diffsrerd from Site Addre") <br /> svwr RumbK Stott 9" <br /> CRY STATE Z1P <br /> PHDNE f1 T APN# LA USE APPLICA77DN/ <br /> 1 ? <br /> PHONE 82 E:. a03 DL7T(UCT <br /> wcAnoN CODE <br /> I ) <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR <br /> Greg Kaiser cNEcx NrLiuNo A ❑ <br /> BUSINESS NAME <br /> Kaiser Commercial Petroleum 20 401-2379 E� <br /> HOME or MAiuNG ADDRESS FAX# <br /> PO Box 1058 ( 1 <br /> CITY Linden STATE CA ZIP 95236 <br /> BILLING ACKNOWLEOGE'MENT: 1, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific ENvraoNMENTAL 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 /> 1 also certify that I have prepared this application and that the work to be perfomred will be done in accordance with all SAN JOAouiR <br /> CouNry Ordinance Codes, Standards,STATE and FEDERAL lam // <br /> APPLICANP3 31GNATURE:,, C� -./ <br /> DATE:-/ <br /> PROPERTY 1 BUSMEN OWNER OPERATOR GER OTHERAUTHORREOADEM <br /> IfAPPucANTIsnotthe&tuNoPARiv.proofofauthorizationtosignIsrequFred Ttrfe <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, the owner or operator of the property located at the above <br /> site address,hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information <br /> to the SAN JOAGUIN COUNTY EwRONMENTAL HEALTH DEPARTMENT as soon as it is available and al the same time it is provided to me or <br /> my representative, f <br /> TYPE OF SERVICE REQUESTED: N O <br /> co�E Cut out existing direct bury spill bucket on tank#1, replace like for like with OPW 210i <br /> W °r° 000Series spill bucket. After inspection and verified, back fill and pour concrete. W t— nzw <br /> os�. <br /> L.) 'z <br /> 0-cccQ zw <br /> a = <br /> w <br /> ACCEPTED BY: EMPLOYEE : DATE; <br /> AWGNEDTO: L EMPLOYEE b: RATE: l�-I� •� <br /> Data Service Completed (if etmady pteted): SERVILE CODE: i PIE: 2 $' <br /> Foe Amount I Co Amount Paid �_'!`l Payment Data O 6 <br /> Payment Type invoice t1 Check If 77 Recei By. <br /> EHD 4802-025 SR FORM(Golden Rnd1 <br /> 0717/08 <br />