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SERVICE REQUEST <br /> Type of Business or Property FACILITY ID 9 SERVICE REpU / <br /> Gas Station / Convenience Store Arco # 6080jT�l q S <br /> OWNER I OPERATOR v <br /> BILLING PARTY❑ <br /> Arco / John Serpa <br /> FACUff NAME <br /> Arco # 6080 <br /> Sn ADDRESS <br /> 85 sn.�cNe,+e.r EaMracr Louise Avenue <br /> Se.s Msmr. s>,m a <br /> Mailing Address (if Different from Site Address) <br /> (Same as above) <br /> CITY STATE ZIP <br /> PHONE fit ext. APN* LAND USE APP=TIDN It <br /> (209) 983-9140 <br /> PHONE#2 SOS DtSTTiICT' LocATxN CODE;,.• <br /> CONTRACTOR I SERVICE REQUESTOR <br /> REQueMR BLLINO PAM <br /> RickH nderson <br /> Susi ESS NAME PHONE# <br /> HQnderson Construction <br /> MauNo ADDaESS FAX 9 <br /> 2080 E. Fremont Street (2091943-5059 <br /> CtrY Stockton STATE CA ZIP 95205 <br /> SILLINGAICKNOWI DGI: EMF : 1, tne uMersgned prvpgrty or busiren owner,opwrer or outhortmd agent of same, aCfTomedge that all sit andla project spec <br /> PUBLIC HEALTH SERNIMES ENVIRONU xrAL HEALTH DWOON hourty dw9e6 aaSoaaled w tM MIS projed or ac%K*will be b"d to me or my business as idwrood on Tres form. <br /> 18150 certify that I have PrePared this applimatlon and trlet the work fb be perlrmr�Q will be dme in at� ir <br /> tlee whA aSMJOA tN Ccurm Ordnance Codes,Slenderd&STATE and <br /> awn <br /> FEnERAL l . ' /// <br /> APPLICANT SIGNATURE: \\. ,/; ' ; , --- DATE: 6/28/99 <br /> PRoPERry/BuswEss OvvNeR 0 OPERATOR/kWQrZ t ❑ OrNEi ALTHCA eD AGEur Office Manage r <br /> NAopur wr is nor the SJUK Pvd of 8WWfarll0n to sign is mquid rifle <br /> AQTHORIZATION TO RELEASE INFORMATION:When applicable,t the owner or operator of the property located at the above sets address,hereby mAoAm the roles"of <br /> arty and all results,geotechnical data arxYor wA=rn@nWsits assessment Inkanatloon b Che SAN JOAam Coma Pusuc HEALTH SERVICES ExvdtaweNTAL HEALTH DrvrslpN as soon <br /> as if is aveMble and at Che same EITIe$b provided to me or my rrepresentadve. <br /> TYPE OF SERVICE REourst> <br /> 7 <br /> COMMENTS: <br /> f.0.-y.� <br /> JUN R s <br /> NtSArq:0"(j$,rnr <br /> ENVIRCNMFN-,AL HF;l F�rvlr'Ps <br /> H UIV�gI�,r�, <br /> INSPECTOR'S SIGNATURE: CONTRACTOR'S SIGNATURE: <br /> APPROVED BY: �\ I LL E!tPL--Y--t C JL,tI DATE: <br /> AssicwwTo: ��1)h �) EMPLOYEE DATE: <br /> L <br /> Date Service Completed (N already completed): SERVICE CoDE: <br /> Fee Amount: j\-I tJ� Amount Paid /� `� ) Payment Date J In L <br /> Payment Type , Invoice 4 Ckeck 0 Received By: <br />