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b—LtS—I�J`J 1=4tiNM I-I tUM N. 4 <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY la 9 SERVICE REQUEST <br /> Gas Station / Convenience Store Arco # 6080 , Cj �\ 'S <br /> OWNER 1 OPERATOR ` I BIUJK PARTY 0 <br /> Arco / John Serpa <br /> FACILITY NAME <br /> Arco # 6080 <br /> SITE ADDRESS East Louise Avenue <br /> 85 Sr""Wftdr orne3on So.w NwM In. <br /> Mailing Address (If Different from Site Address) <br /> (Same as above) <br /> Cm STATE ZIP <br /> PHONE 41 APN# LANo USE APPLICATION 9 <br /> (209) 983-9140 <br /> PHONE#2 a*• SOS OMTRICT LOCATION COOS':,.' <br /> CONTRACTOR I SERVICE REQUESTOR <br /> RE=ESTOR Balm P ❑� <br /> i <br /> Rick Henderson \. <br /> Busmss NAME PHONE# ocr <br /> Henderson Construction (209194,2-5058 <br /> MAnmO AnDRFsS FAX 9 <br /> 2080 E. Fremont Street (2091943-5059 <br /> CrtY Stoc <br /> on STATE CA ZIP 95205 ! <br /> 5 LLING ACKNOWLEDGEMENT: I,me unceralgned property or bwioesa owner,opw=r or authortied agent of Same,ao=Medge Me ad site and/or project spedfic <br /> Pusuc HEALTH SERVICES ENMOMeNTAL HEu_TH OW04 hcurty durges awocWtedl wM Cris projed or acS*gilt be b4led to an or my business as identlfled on anis farm <br /> I abo earthy that t have prepared this applica�an work b vA be dare in atcerua►ce WiM a4 SAN JOAOutN Cawy Ordinance Codas,Standards,STATE and <br /> FEnERAL laws. ` <br /> APMXANT SIGNATURE: DATE: 6/28/99 <br /> PROPERTY/13USINESS CWNER 0 OPERATOR/MANAGER 0 Orwa AunokiZEO AGEtcr 101 Office Manager <br /> IfAmtrAyrigiotivgum ova ofswomtrowtoSir AMquid rifle <br /> AA rdQRtzATIQN TO RELggE INFORMATION;When apptkabie,I,Ute owner or operator of the property located at Ile above site addreim hereby authod n the rotesse of <br /> any and all result,geotediniml dare and/or arrAwmemallsite assessment hkmiadon to the SAN JoAam COUNTY Puauc HEALTH SERVICS ENVAOP ertA.Hi xTH DnnSIQN as soon <br /> as it is avaMble and at me same>tme it b prwided to me or my representatNe. <br /> TYPE of SElwF REoutsTFn: �,_ \ ��✓1't �-' , I <br /> C40Mr1E=: Ysj�" ENT <br /> FCE'VFn <br /> MY29Mg <br /> YSAN <br /> UC CAQUIN CUUN <br /> _NVIRCNMEI TA tHEARV ESIO!` <br /> INSPECTOR'S SIGNATURE: CONTRACTORS SIGNATURE: <br /> APPROVED BY: �f� � EmPL--Y--A: C7L�Ll DATE: <br /> Ass ww To: t C7 EMPwrl:E ik DATE: <br /> Date Service Completed (If already completed): SERVI=Cove `1 "P I E:. 3(), <br /> Fee Amount:J Amount Paid ✓ Payment Date <br /> Payment Type „ invoice ix U C x a Received <br />