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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # SERVICE REQUEST # <br /> Retail Fueling �*o 7124000�5q )tZOOJ 2g2e5 <br /> OWNER / OPERATOR <br /> CHECK If BILLING ADDRESS O <br /> Love 's Country Stores of California <br /> FACILITY NAME <br /> Love 's Travel Stop - Ripon , CA <br /> SITE ADDRESS <br /> 1553 Colony Rd , Ripon , CA 95366 <br /> Street Number Direction Street Name Cit Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 10601 Pennsylvania Avenue <br /> Street Number Street Name <br /> CITY Oklahoma City OK STATE ZIP 73120 <br /> PHONE #1 EXT. APN # LAND USE APPLICATION # <br /> ( Cell : ) 405-687- 1060 245 -340-240 - 000 <br /> PHONE #2 Ex-r. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> Contractor - Western Pump , Inc CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE # EXT' <br /> Western Pump , Inc ( 209 599- 0740 <br /> HOME or MAILING ADDRESS FAX # <br /> 3235 F Street ( ) <br /> CITY San Diego STATE CA ZIP 92102 <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, Slandard STATE aI D laws . <br /> APPLICANT ' S SIGNATUR DATE ; 11 -23 -20 <br /> PROPERTY / BUSINESS OWNER ❑ OPERATOR "AGER ❑ OTHER AUTHORIZED AGENT ® Permitting Administrator, HFA <br /> If APPLICANT is not the BILLLVGPARTY, 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 <br /> above site address , hereby authorize the release of any and all results, geotechnical data and/or environmental/site 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 : L� <br /> COMMENTS : <br /> ACCEPTED BY: ` {—y� > ,� EMPLOYEE # : DATE : <br /> ASSIGNED TO : l� ` (I/7/L�C� Fl EMPLOYEE # : DATE : <br /> GL <br /> Date Service Completed ( if already completed) ; SERVICE CODE : >9� r2�0 P 1 E : 2�� <br /> Fee Amount : od Amount Paid Payment Date <br /> Payment Type Invoice # Check # Received By : <br /> EHD 48-02-025 SR FORM ( Golden Rod ) <br /> REVISED 11 / 17/2003 <br />