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07/23/2003 09:06 2094683433 FIFTH FLOOR PAGE 02 <br /> nA.N JOAQUIN I OUN)EY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property _ FACILITY ID# SERVICS REQUEST# <br /> FUELING FACILITY F:j9��C� (< (� 0—3 <br /> OWNER/OPERATOR `171�'1 <br /> BOYETT PETROLEUM CxECKif 111INGADORESSLJ <br /> FACILITY NAME K W I K SERVE T <br /> SITE ADDRESS <br /> 419 S. MAIN STREET :�:MECA 9��33 <br /> reef Number Direction Street Na a <br /> HOME or MAILINGS ADDRESS (If Different from Site Address) e <br /> POBOX 576277 <br /> Stree!Number St ame <br /> CITY MODESTO STATE ZIP <br /> CA 95357-6277 <br /> PHONE#'I ETT. APN# LAND USE APPLICATION# <br /> ( 209 ) 577-6000 <br /> PHONE#2 EXT. <br /> BOS DISTRICT LpCAT10N CODE <br /> c ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REclUESTOR <br /> FRANZEN-HILL CORPORATION CNECKifBILLIN�ES. <br /> � <br /> BUSINESS NAME PHONE# Err, <br /> FRANZEN-HILL CORPORATION 559 688-2977 3004 <br /> HOME Or MAILING ADDRESS FAx# <br /> 1100 NORTH J STREET 5591688-1467 <br /> CIT" T U LA R E STATE C A zlP <br /> 93274 <br /> SILX.ING ACKNOWLEDGEMENT': I, the undersigned property or business owner, operator or authorized agent of same, <br /> aelmowledge that all site and/or proj ect specific I✓NVIRONME2vTAL HEr1LTH DEPART�f1;NT hourly charges associated with this project or <br /> activity will be billed to me or my business as identified ora this form, <br /> I also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE and l~EDERAL laws. <br /> APPLICANT'S SIGNATURE: Q I c, w � St<mr,w G,�lLG` <br /> DATE: , r7-,;23 0 <br /> PROPERTY/13WNESS OWNER❑ OPERATOR/iMANAGER El OT HER AUTHORIZED AGENT 25e Tinct <br /> 1le <br /> IfAPPLIC AAT is not the BA, ivGPARTY proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: Vvhen applicable,I,the owner or operator of the property located at the <br /> above site address, hereby authorise +I,e release of any and all results, 5eotcclir'cal data and/or environmentaUsite assessment <br /> information to the SAN JOAQUIN COU LhrVIR,ONMENTAL HEALTH DEPARTMENT as soon,as it is available and at th <br /> provided to me or my representative. ?#1 C time it is <br /> TYPE OF SERVICEREQUESTED: \J�C <br /> REPLACE THE PREMIUM LINE LEAK DETECTOR <br /> COMMENTS: <br /> Wb GC�NjY <br /> yPN`CHQP�FPRV\�\V1S N <br /> P�ONt�Ff1jP�F <br /> rptV14� <br /> APPROVED BY;. EMPLOYEE#r: C DATE, X1 <br /> ASSIGNED TO: O <br /> 1`4 ` / - Ci�. EMPLOYEE#: i DATE: <br /> Date Service t:ornpl d (if already completed): <br /> SERVICE t� PI_E <br /> '2 7% <br /> Fee Amount: 7 ' Amount Paid Payment Date <br /> s03 <br /> Payment Type invoice# Check# <br /> L79S3 Received By: <br /> EHD 48-01-025 <br /> REVISED 6-5-02 SERVICE REQUEST FORM <br />