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RECEIVE® <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MAY 18 2017 <br /> SERVICE REQUEST ENVIRONMENTAL HEAM <br /> Type of Business or Property FACILITY ID# SERVICE REQUES CES <br /> ARCO AM/PM Fuel Facility ew X71 <br /> OWNER/OPERATOR <br /> Ranjeet Singh CHECK if BILLING ADDRESS <br /> FACILITY NAME <br /> ARCO AM/PM Manteca <br /> SITE ADDRESS 1904 Daniels Street Manteca 95655 <br /> StraM Number I DI Sire Name City Tip Code <br /> HOME or MAILING ADDRESS (N Different from Site Address) 3115 Cynthia Court <br /> Svc Number SVW Nam <br /> CITY Tracy STATE CA ZIP 95377 <br /> PHONE 91 Exr. APN# LAND USE APPLICATION# <br /> ( 209)579-4014 222-250-014 SPC-16-97 and UPN-16-98 <br /> PHONE#2 Ex. BOS DISTRICT LOCATION CODE <br /> ( i <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR <br /> Alexia Dorsch CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE# En' <br /> Barghausen Consulting Engineers, Inc. ( 425)656-7426 <br /> HOME Or MAILING ADDRESS FAX# <br /> 18215 72nd Avenue S. ( ) <br /> Cm Kent STATE WA ZIP 98032 <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project <br /> or activity will be billed to me or my business as identified on 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 Coder,Standards,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: ���j� IPJ � DATE: C <br /> PROPERTY/BUSINESS OWNERM OPERATOR/MANAGER ❑ OTHERAUTHCHUzEn AGENT 13 <br /> IfAPPL/CANT is nol the BIJ.LINGPARTY.proofofauthoricadon to sign is required True <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable,I,the owner or operator of the property located at the <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the sw time it is <br /> provided to me or my representative. .q <br /> TYPE OF SERVICE REQUESTED: C T <br /> COMMENTS: <br /> H�T/R2/v NCO <br /> h�Ep9RT <br /> "'14 V <br /> . <br /> M <br /> ACCEPTED BY: EMPLOYEE#: DATE: I <br /> ASSIGNED TO: n EMPLOYEE#: DATE: (�j• G`� <br /> Date Service Completed (N already completed): SERVICE CODE: . ✓✓P I E: <br /> Fee Amount: /—� Amount Pai T/ 0V Payment Date $ <br /> Payment Type L Invoice# Check# /03a- Received By. <br /> EHD 40.02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />