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SAN U9000UNTY ENVIRONMENTAL HEALTRDEPARTMENT <br /> Q <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Gas Station FA0003730 S P1 1)6 7S i <br /> OWNER/OPERATOR <br /> CHECK If BIWNG ADDRESS <br /> Derinder Tiwana <br /> FACILITY NAME <br /> Tiwana Gas 8 Food <br /> SITE ADDRESS Hammer Ln Stockton 95210 <br /> 1210 Street Number I Direction Street Name city Zip Code <br /> HOME or MAILING ADDRESS (if Different from Site Address) 1 st Ave Suite B <br /> 601 Street Number Street Name <br /> CITY STATE ZIP <br /> SSWBMMtD <br /> PHONE#1 EXT• APN# LAND USE APPLICATION# <br /> ( 916 )382-4761 l� C <br /> PHONE#2 " ExT• BOS DISTRICT LOCATIONCODE <br /> ( 209 )715.0124 06) 1;k <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> Ronnie Lewis CHECK If BIWNG ADDRESS <br /> BUSINESS NAME PHONE# ExT. <br /> Nucleus Pump Services 915 382-4761 <br /> HOME or MAILING ADDRESS FAX# <br /> 601 1 st Ave Suite B ( 707) 638-0484 <br /> CITY Sacramento STATE CA ZIP 95818 <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 project <br /> 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 JOAQUIN <br /> COUNTY Ordinance Codes,Standards, STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: /G6' #teles DATE: 8/30/17 <br /> PROPERTY/BUSINESS OWNER OPERATOR/MAN.A GER ❑ OTHER AUTHORIZED AGENT m Service Manager(Contractor) <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 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 SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: UST Retrofit PA <br /> COMMENTS: <br /> SEPcotA <br /> �6 2011 <br /> R®NMSXL <br /> TM�NT <br /> H�1.fH DEpA¢ <br /> ACCEPTED BY: Ci�c _' EMPLOYEE#: DATE: _ /- <br /> 44 <br /> ASSIGNED TO: EMPLOYEE#: ® DATE: %_ - /-7 <br /> Date Service Completed (if already completed): SERVICE CODE: P/E: <br /> Fee Amount: 4c C Amount Paid i--�5 Payment Date l <br /> Payment Type Invoice# Check# Received By: <br /> t EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />