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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # SERVICE REQUEST # <br /> GAS STATION 19000 6eop �7 5 ZOO ' 2Z p q <br /> OWNER / OPERATOR MIKE O MAR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME DIAMOND GAS AND FOOD MART <br /> SITEADDRESS 824 EAST YOSEMITE AVENUE MANTECA 95336 <br /> Street Number Direction I 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 ExT• APN # LAND USE APPLICATION # <br /> ( 510 ) 432 -5211 Z 2. I l 1X03 <br /> PHONE #2 Exr. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> 03S b tj <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR TONY MEHROKE CHECK if BILLING ADDRESS ® <br /> BUSINESS NAME TANK-TIGHT SYSTEMS , INC . P91E # 667 -6891 ExT <br /> HOME or MAILING ADDRESS FAX # <br /> 8515 WATERMAN ROAD ( ) <br /> CITY ELK GROVE STATE CA 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 or <br /> 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 : C> �`� �ti��� o � �� DATE : 9/27/2021 <br /> PROPERTY / BUSINESS OWNER ❑ OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT 0 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 above <br /> site address , hereby authorize the release of any and all results , geotechnical data and/or environmental/site assessment information <br /> to 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 . �I <br /> TYPE OF SERVICE REQUESTED : j� /� • /. A , <br /> COMMENTS : ?I / ` 'J <br /> SAN SEp ? � p2 <br /> l% <br /> TIRO ON c V <br /> V T y <br /> ACCEPTED BY: ( \^U �{ �' �/ �� EMPLOYEE #: DATE: <br /> ASSIGNED TO : GL L �, EMPLOYEE #: DATE: <br /> Date Service Completed ( if already completed) : SERVICE CODE : <br /> Fee Amount: ✓� � Amount PalaL/ k / X60 Payment Date` <br /> Payment Type eXXJ Invoice # Check # QS23%% Receive By : <br /> EHD 48-02-025 SR FORM (Golden Rod) <br /> 07/17/08 <br />