Laserfiche WebLink
RECEIVED <br /> JUL 17 2018 <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT ENVIRONMENTAL <br /> SERVICE REQUEST HEALTH nEPA.RTMENT <br /> Type of Buelness or Property FACILITY ID# SERVICE REQUEST# <br /> C.-store L 3V-W-7c/40<- <br /> 010MER 1 OPERATOR CHROKlf BILLI o AanRess❑ <br /> Vakram Vohea <br /> FACILfTY NAME <br /> slseADOR�ss 1399 E Yosemite Ave. Manteca 95336 <br /> b et a 11 Cade <br /> HomE Or MAime ADDR£83 (If alfferent from Site Address) <br /> StreetNum6a SUM N <br /> CITY STA79 zip <br /> PHONE 01 &T. APN tlWo Use APFLIaATIott H <br /> (209)823-3460 5M �J <br /> PHONE h2 exT. 121%0ts ICT teCATtoN C OE <br /> ( 1 <br /> CONTRACTOR I-SERVICE REQUESTOR n <br /> REauESTOR Bonnie Garber CHECK it BILLIma AoD essL.l <br /> BusiNEes NAME PHONE ext. <br /> Donlee Pump Company (209)537-9396 <br /> Homo or MAILING ADDRESS WN <br /> 2825 Railroad Ave. (209) 537-9398 <br /> CITY rpres STATS CA ZIP 95307 <br /> BILLING ACKNOWLEDGEMENT': 1, the undersigned preoperty or business owner, operator or nuthortied agent nr same, <br /> noKnowledgo that all site and/or projeot speeitie BNVIRoMmrNTAL I-IFALTii Dpi)ARWENT hourly charges assaeinted with Ibis pmjcct <br /> or notivity will he pilled to me or my business as identified on this foot. <br /> I also certily that I have prepared this application and that lho work to bo porl'ortned will ho dorso in accordattoo with all SAN foAQVDI <br /> comw)-Op Whrmrce Codes,,Slandnrriss,S'PA'TE Rud FRDFRI t ,l�vs. / <br /> APPLICANT'S SIGNATURE: J Dxrv: <br /> PROPERTY/131W.VR.S5 OWNP.R OPNR.woR/M,tN,t 0TI19R AU'rRoRi7.io AGENT l.1! t^nntra�tnr <br /> I/',rImvc,-IM'is Ho!the AILLINa PAlrrt'.Proof of outhorimfiotr to sign It required 7YNe <br /> AUTHOR: AT16N TO RELEASE INFORMATION: When applicable,1,the.owner or eperatnr or the properh•loonted al Ute <br /> above alto addmatA, hereby authorize the roloaso or any and all results, geotechnical data and/or Om'imnmcntal/.it :mal <br /> ntronnntion to the SAN JOAQUIN COUNTY EmnRom•IETYI'AL HEALTH DRPAWEMUNT as sane as it is availn 10 and 111 the s t f <br /> provided to use or my representntive. C A <br /> TYPE OF SERVICE R£QU£STED: o <br /> f7,;l e �® <br /> COMMENTS: Remove existing Diesel spill bucket due to failed annual testing SAN,o ' ° 2 j8 <br /> ETV tr?QUI <br /> _ H�`T <br /> F T <br /> AooEPTeo BY: BMPI.oY68 I: DATE: <br /> AsSIGNEIDTO; -V-7-7 EMPLOYes#; DATE: <br /> Date Servleo Completed (if already completed): SERVICECOOE: PIE:2W- <br /> Fee Amount: Amount Pal Payment Date g �g <br /> Payment Type Invoice# Check# 361 Roely d fay: <br /> EHC1 48-02.025 SR FORM(Golden Rod) <br /> ��112� rxe4 <br /> REVISED 11/17/20M l[ !I V e� <br />