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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # SERVICE REQUEST 9 <br /> Convenience Store 10180675 - �t)L! ) SPI SkOWOLRD <br /> OWNER / OPERATOR CHECK if BILLING ADDRESS ® <br /> Ruchl Vohra <br /> FACILITY NAME <br /> Tiger Express <br /> SITE ADDRESS <br /> 1399 Yosemite Ave, Manteca 95336 <br /> Slreot Numbor Dlrecl o Street Name cit ZI Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Slroel Number Street Name <br /> CITY STATE ZIP <br /> PHONE #1 Exr. APN # LAND USE APPLICATION # <br /> PHONE <br /> //2 EXT• BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR Bonnie Garber CHECI< If BILLING ADDRESS <br /> BUSINESS NAME PHONE # Exr• <br /> Donlee Pump Company 209 637-9390 <br /> HOME or MAILING ADDRESS n Q FAX # <br /> Ol , It V` ( 209 37.9398 <br /> CITY Ceres, CA, 96307 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 /> 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 IaWS. <br /> APPLICANT' S SIGNATURE: I DATE: <br /> PROPERTY / BUSINESS OWNER ❑ OPERATOR / N 3ER ❑ OTHER AUTHORIZED AGENT <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, PAYMENT <br /> TYPE OF SERVICE REQUESTED; UST Retrofit D <br /> 12 <br /> COMMENTS: R J U Z Oz <br /> Install new Diesel OPW Droptube ( like for like) due to failed during OFP Test . SAN JOAOIIIN COI NTY <br /> rNVIROUNIENT1 L <br /> I IEALT11 DEPARTN ENT <br /> ACCEPTED BY: � EMPLOYEE #: DATE; �V - ZU2L <br /> ASSIGNED TO: �Lt Iv jai EMPLOYEE #0 DATE: <br /> Date Service Completed (if already c mle d): SERVICE CODE: I '1 �] L " IV P / E: 2e <br /> Fee Amount: a�l(� , QC) >( �ty\t Amount Paid ( � Payment Date2 f <br /> Payment Type L! Invoice # Ctt ck # 1 L� 0, 1 L Received y : h <br /> EHD 48-02-026 SR FORM (Golden Rod) <br /> 07117/08 <br />