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b-2Li-I yJJ 2:4bi'M t-HUM P. 4 <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Gas Station / Convenience Store Arco # 595 C I <br /> -0*1 OPERATOR DLUK PARTY 0 <br /> Mercedes L. Acosta <br /> FACILITY NAME <br /> Arco # 595 <br /> $ME ADDRESS North Highway 99 -T <br /> 6100 sew Nu"44 1 $"N ow" �,n <br /> Mailing Address (If Different from Site Address) <br /> Madeline Scannavino (Property owner) 5463 Cherokee <br /> CITY STATE ZIP <br /> Stockton CA 95205 <br /> PHONtE lit *• APN# LAND USE APPur.ATION 9 <br /> Q09) 931-5976 (site phone) <br /> PHONE#2 SCS,D*TRicr LocATION CODE;,: <br /> 31 404-5385 (property owner) " <br /> CONTRACTOR 1 SERVICE REQUESTOR <br /> REaUESTOR Bu.LM PARTY <br /> y, <br /> Rick Henderson <br /> USNESS NAME PHONED <br /> Henderson Construction (2091943-5058 <br /> MAILING ADDRlwsS FAX 9 <br /> 9QA0 E- Frpmoj�L Street (209) 943-5059 <br /> CITY qfookfon STATE CA ZIP 95205 <br /> 91LLING ACKNOWLEDGEMENT: I,me urwerslgned property or bwinsss Dotter,operitnr or atrUlortted agent of same aCkRCwledge that atl andla prood specific <br /> Pueuc HEALTH SEAVrCES E.gVSLNM4TAL HEALTH DrMCN lloudy dtarged 33SOGaD@d w1h M13 wojed or acxiv wid be SW m me or my business as idendlled on this form. <br /> I also certify that I have prepared this ata, an j thea the work m be Wbrod wd be done n accontance wide aU SAN JOAM N COUNTY Ordgivnce Corea,Sb»dards,STATE and <br /> FEhERAL laws. / <br /> APPLJCANT SIGNATURE: ( �7'r t // ` '2-- DATE: <br /> PSCFERTY I SUS NESS OWNER Q OPSWOR/MANAGER 0 OrmER ALM40R=AG&a $1 Office Manager <br /> n aor uawr a na tAs fi{ P aool o/wdio►Wrna n to sign is nqua.d rifle <br /> A THORIZATION TO RELEASE iNFORMAMN:When applicable,I,dte owner or operator of the property located at dte above site address,hereby ewthoffze the release of <br /> arty and all result,geotechrriml data arKUor emhonmerltallsbe assessment inbRna4on m the SAN JOAOtatt C uNTY PusLc HEALTH SEwrEs Em RommwrAL HEALTH OmsscN as soon <br /> as d is avant*and at the Same tbne it is provided to me or my representative. <br /> TYPE OF SErW8 REQUESTID: <br /> COMMENTS: \ <br /> PIN` N7 <br /> FIE 0CFE , <br /> WN 2 1996 <br /> SAN JOAQUIN CO.iN7V <br /> PUBLIC HEALTH SET3Vn:ES <br /> INSPECTORS SIGNATURE: CONTRACTOR'S SIGNATURE: i F 'olvisic <br /> APPROVED BY: EIIPt_^Y��IT (50 � ' DATE: <br /> ASSIGNED TO: L<' Y \ EMPLOYEE 0: C(>7 DATE: <br /> Date Service Completed (N already completed): SExvIGE CODE: l.c P I E:. <br /> Fee Amount: -� ' b�_ Amount Paid /") i Payment Data " <br /> Payment Type Invoice 4 Che6 0 Recttved BY <br />