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SAN JOAQUI10OUNTY ENVIRONMENTAL HEALTIOEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITYID# SERVICE REQUEST# <br /> Gasoline Service Station <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 Zip 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 ExT' SOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR Roy Soffe X <br /> CHECK If BILLING ADDRESS /� <br /> BUSINESS NAME Triangle Environmental, Inc PHONE# EXT. <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 available and at the same time it <br /> is provided to me or my representative. 17 17 <br /> TYPE OF SERVICE REQUESTED: / <br /> COMMENTS: <br /> APPROVED BY: EMPLOYEE#: DATE: 04G. <br /> ASSIGNED TO: V EMPLOYEE#: DATE: <br /> Date Service Cam ped (if already completed): SERVICE CODE: P,/ E: .3o <br /> Fee Amount: Amount Paid I Pa trent Date <br /> Payment Invoice/# T6eclk# Received By: <br /> T ' <br /> EHD 48-01-025 SERVICE REQUEST FORM REVISED 6-5-02 <br />