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IUL 17 2013 <br /> SAN,IOAQUIN COUNTY ENVIRONMENTAL HLIALTHDI:PARTMF,NT ENVIHONVIEN'IAL. <br /> SERVICE REQUEST 11EAl.TI-I [�FTA.RTMEW <br /> Type of Busllless or Property rFACILITY ID# SERVICE REQUEST# <br /> C.-,-.tQre - [-F� U _ J v--OO`7 9 40 S <br /> OWNER I OPERATOR <br /> Vt7hEa C)fEOKIft31LLIttOADDRESS Vkram ® <br /> FACILaY NAME <br /> SITEAODRBSS 1399 E Yosemite Ave, Manteca 95336 <br /> s er e oShol Hanlecity <br /> zI ecce <br /> HOME or fAAWHO ADDRESS (If olfferent from Sftc Addross) <br /> ___ SrieatHnmbo St/eol ttamo ___ <br /> CITY STATE Zip <br /> PHOIlE fit It". APN tt � WD Use APPt.IcAYloll 0 ^T <br /> (209)823-3460 Qb`oJM <br /> PHONE#2 exr. BOS DIST ICT LOCATI011 C409 <br /> CONTRACTOR/ SERVICE REQUESTOR__ <br /> REQUESTOR CHECK if ILLI Lie Bonnie Garber _ <br /> Buaulees NAME PHOHcff -- ext. <br /> Donlee PumpCompany 1209)537-9396 <br /> Hoin or MAILINo AvoRESS Ful# <br /> 2825 Railroad Ave. _ ( 209L_537-9398 <br /> CITY Ceres__. SrnTe CA -ZIP 95307 <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned peoporIly or bnxlness olnior•, uperatlor or authorked nuent ur.4'11110, <br /> nolnowledge that all site rindlor project speoitie ENVIRONWNTAL I]VALT1I DLPARWENT hourly charges(ssoein(ed wilh thi,pr0iC0 <br /> or notivity will bi)Hilcd to me or my husinexs as identilicd on this fomt. <br /> I also certify that I have prepared this appliofition and that tho work to bo porlimned n'ill ho Bono in accordance with ill)SAN.10AOIT's) <br /> Cot INrY(hzttllmtc<Coi les,Standal VIS,S'IXIB find r-RDPRAI I`1vS. <br /> APPLICANT'S SIGNATURE1 � 41a", <br /> PROPKRTYtI111'sInsssO%YNYR[3 O!'HnITOR/�f,1N,1( UTHEIiAU'rHONI'/,FDACf:Vt'LLt^ r.f)ntrgrfnr _ <br /> 1f,dt'l'LIC.qNT is 1101 1114o BILLING Pdirrl'.proof of authoncation to sign Is regtdred Thle <br /> AUTHORMATION TO RRLFASE I CO MATIONa When nnplicablo,1,the nwner or nperatnr firtllc Ift'011CHY Inomod nI IhC <br /> nboNre situ ndtlras9, herohy authorize the release or any and nil results, geolechaicnl data and/or onvironnlelihill,iw jzt, irnt <br /> informntion to the SAN JOAQUIN COUNTY RwROmiI mrAL 14HAtvi DPPAR•C.. .w ns soon as it is avili)ahle and at ill <br /> provided to me or my representative. nn dr <br /> TYPE OF SERVICE REQUESTED <br /> COM MEa1S: ---��-- <br /> Remove existing Diesel spill bucket due to failed annual testing �o 2 ��> <br /> N�THD� �� n' <br /> �T/tTF <br /> T <br /> l"eetp oyria Il: DATE: <br /> AOOEPTED 8Y; --d - GL <br /> AsSIGNSD T0: ErAPLOYBE�l: DATE: ' —I t <br /> Date Service Corripfetod (If alraedy completed): SERVICE CODE; � , P 1 E:2�0 <br /> Fee Amount: '�'. . Amount Pal r fs'�v� Payment Date 7 S <br /> Invoice it Check# Reeely d By: <br /> Payment Type ` 36 <br /> EH0 48-02-026 QL� �7( 3R FORM(Golden Rod) <br /> REVISED 1 1 11 712 0 03 [ V � <br />