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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST _ <br /> Type of Business or Property FACILITY ID # SERVICE REQUEST # <br /> C - Store 10180561 fAOOODO ( <br /> OWNER 1 OPERATOR I <br /> GHEC!( If BILLING ADORESSE] <br /> Balwinder Singh <br /> FACILITY NAME <br /> Escalon Mini Mart <br /> SITE ADDRESS i <br /> fpg7 Yosemite Ave . Escalon <br /> S=Numberocllo Street ame c1tv zip Code <br /> HOtdE or MAILING ADDRESS (If Different from Site Address) j <br /> Street Number Streot Name I <br /> CITY STATE zip <br /> PHOtIE #1 EXT. APN # LAND Us EAPPLICATI ON 11 <br /> PHONE #2 EXT, BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR CHECK If BILLING ADDRESS <br /> Bonnie Garber <br /> BUSINESS NAME PHONE # ExT. <br /> Donlee Pump Company r <br /> HOME or MAILING ADDRESS FAX III <br /> 2825 Railroad Ave . ( 209) 537 -9398 <br /> CITY STATE ZIP <br /> CAres GA . 95307 <br /> BILLING ACKNOWLEDGEMENT: 1 , 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 /> 1 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 ; DATE ; <br /> PROPERTY I BUSINESS OWNER ® OPERATOR / MANA ERS ® OTHER AUTHORIZED AGENT <br /> If APPLICANT is not the BILLING PARTY, proof or authorization t0 sign Is required Title <br /> AUTHORIZATION TO RELEASE INFORMKnON : 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 pfovided to me or <br /> my representative . <br /> TYPE OF SERVICE REQUESTED : C • ` � <br /> COMMENTS: D <br /> Install new Phil Tite Drop Tube 87 bucket . JAN 28 ?O? <br /> S,qN <br /> HEgLTH p PAENTq� TY <br /> RTM T <br /> ACCEPTED BY: V EMPLOYEE M DATE$ I /� (� ZZ <br /> ASSIGNED TO : EMPLOYEE # : DATE; / ZL� ZZ <br /> Date Service Completed ( If already completed) : SERVICE CODE : quP1 E; <br /> Fee Amount ; L� �� Cue Amount Pat !=(5( Payment Date <br /> Payment Type h1Vo1Ce J. Check # . Recelved By ; <br /> EHD 48-02-025 SR FORM (Golden Rod) <br /> 07/17/08 <br />