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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or LProperty FACILITY ID # SERVICE REQUEST # <br /> �, ill' <br /> C-store Q� <br /> OWNER / OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> Escalon Mini Mart <br /> SITE ADDRESS 95320 <br /> E . Yosemite Ave . Escalon <br /> ' 1097 Street Number Direction I Street Name c1tv Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE #1 ExT• APN # LAND USE APPLICATION # <br /> ( ) <br /> PHONE #2 ExT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR CHECK if BILLING ADDRESS <br /> Donlee Pump Company <br /> BUSINESS NAME PHONE # ExT . <br /> 209 537-9396 <br /> HOME or MAILING ADDRESS FAX # <br /> 2825 Railroad Ave . ( 209 ) 537-9398 <br /> CITY Ceres , CA. 95307 STATE ZIP <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 or <br /> activity will be billed to me or my business as identified on this form . <br /> 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 SIGNATUR . DATE : It <br /> PROPERTY <br /> c/ <br /> PROPERTY / BUSINESS OWNER ❑ OPERATOR / M hAdER ❑ OTHER AUTHORIZED AGENT Admin . <br /> If APPLICANT is not the BILLING PARTY, proof of authorization to Sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION : When applicable , 1 , the owner or operator of the property located at the above <br /> site address , hereby authorize the release of any and all results , geotechnical data and/or environmental/site assessment information <br /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It IS available and at the same time It Is provided to me or <br /> my representative . ppm <br /> TYPE OF SERVICE REQUESTED : <br /> COMMENTS: <br /> 2019 <br /> LJ rez SANJO"�NVI b0 M��TA N7, <br /> ACCEPTED BY : 'v I V CW a� EMPLOYEE # : DATE : . 2011 <br /> ASSIGNED TO : EMPLOYEE #: 00 <br /> DATE: vvv-- �20 9 <br /> Date Service Completed (if already completed) : SERVICE CODE : ( (� PIE:aO 1 <br /> Fee Amount: Amount Paid �S(� {� 0 Payment Date 5 <br /> Payment Type ( Invoice # Check # Rec ived By : <br /> EHD 48-02-025 SR FORM (Golden Rod) <br /> 07/17/08 <br />