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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # SERVICE REQUEST # <br /> Gasoline dispensing facility WUU0 <br /> OWNER / OPERATOR <br /> vinash singh CHECK if BILLING ADDRESS ❑ <br /> FACILITY NAME <br /> dino mart <br /> SITE ADDRESS <br /> 1001 East Yosemite Ave Manteca <br /> Street Number Direction Street Name city Z10 Code <br /> HOME Or MAILING ADDRESS (if Different from Site Address) <br /> 253 Street Number Tissot dr Street Name <br /> CITY Patterson STATE ca ZIP 95623 <br /> PHONE #1 ExT. APN # LAND USE APPLICATION # <br /> ( 510 ) 557-4508 22z <br /> PHONE R ExT. l BOS DISTRICTLOCATION CODE <br /> ( ) M <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> Tony Mehroke CHECK If BILLING ADDRESS ® <br /> BUSINESS NAME PHONE # EXT• <br /> Tank-tight systems INC . 667-6891 <br /> HOME or MAILING ADDRESS FAX # <br /> 8515 Waterman RD ( ) <br /> CITY Elk Grove STATECA ZIP 95624 <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 : �16 �� ��Yo ( �� DATE ; 5/03/2021 <br /> PROPERTY / BUSINESS OWNER ❑ OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT is not the BiLLING PARYT proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: <br /> When applicable I the owner oroperator of the property located at the <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmentaysite 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 : T p 1 p <br /> COMMENTS: RiEFQ <br /> MAY D <br /> SAN UGq Q <br /> ' NFAL V I RGNMEN r , <br /> ACCEPTED BY: eyd Y42�fJ -C? EMPLOYEE #: DATE: <br /> ASSIGNED TO : A 'vv"` n p /J �/� EMPLOYEE #: DATE: <br /> Date Service Completed (if already completed) : SERVICE CODE: P I E1 <br /> 119 1A <br /> Fee Amount: dD Amount Paid ? 4 �( Payment Date S 7 <br /> Payment Type Invoice # Check # 201 s g X Received By: <br /> EHD 48-02-025 SR FORM (Golden Rod ) <br /> REVISED 11 /17/2003 <br /> I <br />