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' NED <br /> nv <br /> SAN JOAQUIN COUNTY ENVIRONNIENTAL HEALTII DEPARTtYEMl iUr'ilvlEN'.�A' y TH <br /> SERVICE REQUEST PERMIT/SER1/!CES <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Gasoline Service Station 'SOW V <br /> 81 <br /> OWNER/OPERATOR <br /> ASP Petroleum Inc.c/o Sarvjit Singh CHECK if BILLING ADDRESSEY <br /> FAeiuTY NAME Arco aWpm Manteca <br /> SITE ADDRESS244 1��S Crestwood Avenue Manteca as33s <br /> Street Nu ber I DlmcttQnCRV Zip Cod <br /> HOME or MAILING ADDRESS (if Different from Site Address) 3a19 Escena Court <br /> Street Number Street Marne <br /> CITY Turlock STATE CA ZIP <br /> 95382.0490 <br /> PHONE#1 ExT• APN# LAND USE APPLICATION# <br /> (209 )740-5500 portion of 216-060.01 <br /> PRONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR Chds Brown CHECK If BILLING ADDRESS❑ <br /> BUSINESS NAME PHY Exr' <br /> PM Design Group,Inc. /if 921-1204 <br /> HOME or MAILING ADDRESS 2455 Bennett Valley Road,Ste.A-102 FAX# <br /> t ) <br /> CITY Sante Rosa STATE CA ZIP 95404 <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 ENVIRONNIENTAL 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 la%YS. C. <br /> c7 <br /> APPLICANT'S SIGNATURE:� `�j /f�. DATE: C <br /> PROPERTY/BusINEss OWNER El OPERATOR/MANAGER ❑ OTHER AUTnORIZED AGE,iT❑ <br /> YAPPLtCA,NT is not the BILItnc PARTE proof of andiorizahion to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORAIATION: When applicable,1,the owner or operator of(lie property located at the <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmentaUsite assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as Soon as it is available and ie Sallie time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: 51 <br /> COMMENTS: ( g <br /> SA/V j0 QU 417 <br /> CNV/z0 !JV COVAI <br /> �FLTH D PAR�ELTY <br /> ACCEPTED BY: EMPLOYEE#: 0, DATE: 0,a- 1 <br /> ASSIGNED TO: n —AaA EMPLOY EE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: 3 P 1 E. a <br /> Fee Amounty Amount Paid ��� (Q — Payment Date IN3 <br /> Payment Type f Invoice# Check# Received By: (Z <br /> EHD 48.02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />