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HEGaVED <br /> SAN.TOA*COUNTY ENVIRONMENTAL REALTROARTMENT r,,., . <br /> SERVICE REQUEST <br /> . APR 3 O 2015 <br /> Type of Business or Property ^JFFACILITY ID# SEEJtR�VIICCEw RO N ENTAL. <br /> ✓�\ /�./� Y r:B'^TI- �rra1 T�ACAIT <br /> Gas Station V <br /> OWNER/OPERATOR <br /> Mandeep s. Dua CHECK if BILLING ADDRESS <br /> FACILITY NAME <br /> Super Stop <br /> SITE ADDRESS (n� IAction <br /> Main ST Street Name Mantecae 9!gy. <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 APN# LAND USE APPLICATION# <br /> ( 2091 815-5180 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION C DE <br /> ( ) <br /> CONTRACTOR 1 SERVICE REQUESTOR <br /> REQuESTOR <br /> Carrie Miller CHECK if BILLiNIi ADDREss <br /> BUSINESS NAME PHONE# EXT. <br /> Elite IV Contractors 209 461-6337 <br /> HOME or MAILING ADDRESS FAX# <br /> 2535 Wigwam Dr_ (209 ) 461-6342 <br /> CITY Manteca STATE CA ZIP 95205 <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific FNSfIRoNNIFNTAL IIEAL-ru DFPARTmENr 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 1 have prepared this application and that the work to be performed will be done in accordance with all SAN Jo,QuiN <br /> COUNTY Ordinance Codes,Starxiards -ST ATL and F LDEI2AL laws. <br /> APPLICAN'I'S SIGNATURE: f 'r i.'. %,•' `_ DATL: 4/30/15 <br /> PROPERTY/Bash]ss OWN ERO OPERATOR/NLI:VAGER OTHER AUTHORIZED AGE'S-r❑ Office Manager <br /> Ifr3PPL c MT is not the Bji;LN'G 11AICY,proof of authors;anon to sign is required Title <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 S.xN JoAQLTN CouTrrY EI ArmoNT% rrAL I ILAt_'rt-1 DFPART.f, TNT as soon as it is available and at the same time it is <br /> provided to me or my representative. <br /> i c <br /> TYPE OF SERVICE REQUESTED: Impact Valve Not Closingon#/374(87) W—fr `,�I G <br /> COMMENTS: <br /> APR 1 <br /> SAN JOAQUIN CO NTY <br /> ENVIROMENT L <br /> HEALTH DEPART ENT <br /> ACCEPTED BY: ,,,j EMPLOYEE M DATE: C. <br /> ASSIGNED TO: _1 IA 0 EMPLOYEE M DATE: S <br /> Date Service Completed (if already completed): SERME CODE: PIE: <br /> Fee Amount: �!;III p cc' Amount Paid 1 3 10,O p Payment Date 3 l S <br /> Payment Type i5 Invo[ce# //,� Check# Received By: <br /> EHD48-02-025 CZto)nv -0 1D37 O SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />