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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # SERVICE REQUEST # <br /> Convenience Store 10180675 fj�t✓' � V) D - <br /> OWNER / OPERATOR <br /> Ruchi Vohra CHECK If BILLING ADDRESS ® <br /> FACILITY NAME <br /> Tiger Express <br /> SITE ADDRESS Yosemite Ave. Manteca 95336 <br /> 399 Street Number Direction Street Name Cil 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 /> ( ) <br /> PHONE #2 ExT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> Bonnie Garber CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE # ExT. <br /> Donlee Pump Company 209 537-9396 <br /> HOME or MAILING ADDRESS FAX # <br /> ( 209 �37-9398 <br /> CITY Ceres , CA. 95307 STATE ZIP <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, p� <br /> APPLICANT' S SIGNATURE : DATE : <br /> PROPERTY I BUSINESS OWNER ❑ OPERATOR I 13OTHER AUTHORIZED AGENT Ad <br /> If APPLICANT IS not the BILLING PARtN)GER <br /> 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 /> t0 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. PAYMENT <br /> to <br /> D <br /> TYPE OF SERVICE REQUESTED : UST Retrofit ��yy <br /> COMMENTS : JUN 022 <br /> Install new Diesel OPW Droptube ( like for like) due to failed during OFP Test . SAN JOAQUIN COt NTY <br /> ENVIRONMENT L <br /> IIFALTH DEPARTN ENT <br /> ACCEPTED BY: <br /> sot" Riv� rQ EMPLOYEE #: DATE: ;G 20 <br /> ASSIGNED TO: Q ! EMPLOYEE #: DATE: <br /> Date Service Completed ( if already co m led) : r SERVICE CODE: � q ._ �(� � PIE: <br /> Fee Amount: y5� . ( >( �� Amount Paid / Payment Date 3b L <br /> Payment Type �S �- Invoice # pit ck # f Cj UI b (O Received y : <br /> EHD 48-02-025 SR FORM (Golden Rod) <br /> 07/17/08 <br />