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. SAN JOAQUIIs*UNTY ENVIRONMENTAL HEALTIEI&PARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # SERVICE REQUEST # <br /> Gasoline Service Station 59,100:3-114Y <br /> OWNER/ OPERATOR Conoco Phillips ❑ <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME Conoco Phillips Site#30877 <br /> SITE ADDRESS <br /> 1700 Yosemite Ave Manteca 95336 <br /> Street Number Direction Street Name City Zin Code <br /> HOME or MAILING ADDRESS(If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 209 823 7676 ExT. APN# LAND USE APPLICATION# <br /> PHONE#2 Ems' BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR Roy Soffe Y <br /> CHECK It`BILLING ADDRESS /\ <br /> BUSINESS NAME Triangle Environmental, Inc PHONE# Exr. <br /> (818)840 7020 <br /> HOME or MAILING ADDRESS 2525 W. Burbank Blvd FAX# <br /> (818) 840 6959 <br /> CITY Burbank STATE CA ZIP 91505 <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 ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this <br /> project 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 <br /> JOAQUIN COUNTY Ordinance Codes,Standar , T and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: 8/2/2004 <br /> PROPERTY/BUSINESS OWNER ❑ OPERATOR, NAGER ❑ OTHER AUTHORIZED AGENT X <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at <br /> the 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 availal� m"i 81}I"i'me time it <br /> is provided to me or my representative. RECEIVED <br /> TYPE OF SERVICE REQUESTED: f T e <br /> COMMENTS: AUb 92004 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH EPA TMENT <br /> APPROVED BY: r EMPLOYEE#: DATE: <br /> ASSIGNED TO: V U MPL YEE#: DATE: <br /> Date Service Com1 ted (if already completed): -7 22 SERVICE CODE: P / E: 3d <br /> Fee Amount: C Amount Paid Payment Date ? t:- <br /> Payment Invoice # Check# Received By: <br /> Ty e <br /> EHD 48-01-025 SERVICE REQUEST FORM REVISED 6-5-02 <br />