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U GiJ—I JJJ G:unl-I I r F.ul,i <br /> f <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Gas Station / Convenience Store Arco # 595 (J , <br /> I ODF3tATOR t/ DUIK PARTY 0 <br /> Mercedes L. Acosta <br /> FACILITY NAME <br /> Arco # 595 <br /> Sn-E'ADDRESS North Highway 99 <br /> 6100 S"drruegr I OL1603%n I Sir"of&" Safi? <br /> Mailing Address (If Dlffernrtt from Site Address) <br /> Madeline Scannavino (Property owner) 5463 Cherokee <br /> CrTY STATE ZIP <br /> Stockton CA 95205 <br /> PHONE 41 ea. APN# LAND USE APPLXATION# <br /> R09) 931-5976 (site phone) <br /> PHONE#2 W. BCS D*TRICT LOCATION CODE;- <br /> 31 404-5385 ( ro erty owner) <br /> CONTRACTOR I SERVICE REQUESTOR <br /> REGUESTOR B111rtKI PAR <br /> Rick Henderson <br /> Suswss NAME PHONE# torr. <br /> Henderson Construction (209) 943-5058 <br /> Nmmo ADDRESS FAX 9 <br /> 902n E- FrpmaQt Street (209) 943-5059 <br /> Crnr <br /> STATE CA LP 95205 <br /> 5ILLING At;KNOWI. 01; GEMENT: I,Tie ursgnM prvPerty'x bwine:s owner,ogrrtor or outhortrad agent of sacu adcrfawkdge Qtat a0 site nndlor piojett epecfic <br /> Pusuc HEALTH SERVICES EwlaotatFxtAL HEALTH DtvtsloH Murry durges aasoda*d wtM Mh wood or aaS*wid be Wed to me or my business as idwtW on Ota torn <br /> 18130 certify that I have prepared thh appricalbrf and trteA the welt b be pedvmwd wd be done in amordance wRh all SAM JOAaJtN CWM Ordinanaa Codn Standards.STATE and <br /> FEDERAL laws. <br /> APP-CANT SIGNATURE:_ DATE: <br /> PPOPERTY/BUSINESS OWNFR 0 OPERATOR f MANAGER 0 OTHER Aur,4Pj ED AGPNr $ O f f i c e Manager <br /> IrApftcwrirnot ft G&LM moor,enruro rto,ipgmgt*w rifle <br /> AQTHORZAMQN TQ RELEASE INFORMATION:When applicable,t Ile owner or operator of the property located at the above sb address,hereby"oen the release of <br /> any and all results,geotechnical dare antgor @ny%oamenW3b assessment Intom udon to Me SAN JOAam COUNTY PUSUC HEALTH SERVICES ENvtRo veaif.HFxTH DEY18lON as soon <br /> as A is avalia*and at the same Irma It a provided to me or nrf representative. <br /> TTPEOF5E7iVICEREQUESTED: �,, [ Ce� <br /> COMMENTS: I <br /> it <br /> 9 Igo <br /> snr ,r <br /> INSPECTOR'S SIGNATURE: 1'UIWU !s< . <br /> COMTRACTDR'S SIGNATURE: i <br /> APPROVED Ery: � - tC' EMPf.^Y--I}: ���� ( LATE: <br /> ASSIGNED TO: nJ S C"lam EMKOTE:a: DATE: <br /> Date Service Completed (H already completed): SERvtCE CODE P I E: <br /> Fee Amount -�?� ��� Amount Paid rt II , l Payment DateW. <br /> Payment Typet Invoice 0 C Ica Received ey: l <br />