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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # SERVICE REQUEST # <br /> FUEL DISPENSING RETAIL W674 14P0D11q � r� 0 X53 -70 <br /> OWNER / OPERATOR JATI N AN EJA <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME SAVE ON FUEL <br /> SITEADDRESS 420 W YOSEMITE AVE MANTECA 95337 <br /> Street Number Direction I Street Name Cit 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 /> PHONE #2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR STEFANIE CROWE <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAMEPHONE # ExT. <br /> 916 <br /> TANK-TIGHT SYSTEMS , INC . 667 -6891 <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 : n.rimfee DATE : 05/ 17/2022 <br /> PROPERTY / BUSINESS OWNER ❑ OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT ® OFFICE ADMIN <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 . JOA <br /> TYPE OF SERVICE REQUESTED : UST RETROFIT / REPAIR PERMIT R NT <br /> COMMENTS : ` D <br /> TO BREAK CONCRETE AND REPLACE 87 DIRECT BURY OPW SPILL BUCKET WITH LIKE FOR LIKE . AN ? , <br /> HE� RpNorOIV <br /> 2� <br /> ACCEPTED BY: � r \ . EMPLOYEE # : DATE: Z NT <br /> Y 2 <br /> ASSIGNED TO : Sip EMPLOYEE # : DATE : <br /> Date Service Completed (if already completed) : — SERVICE CODE : ��C1 P 1 E : � <br /> Fee Amount: Amount Pa ��� Payment DateCOO <br /> Z 2 � <br /> Payment Type Jam— Invoice # Check # / I 70ct 2L Received By : <br /> EHD 48-02-025 SR FORM (Golden Rod) <br /> 07/17/08 <br />