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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> TRUCK STOP/CONVENIENCE STORE <br /> OWNER/OPERATOR CHECK if BILLING ADDRESS❑ <br /> APNA PETROLEUM CORPORATION <br /> FACILITY NAME <br /> AHERN TRUCK STOP <br /> SITE ADDRESS <br /> 29700 Street Number I DiAHERN RD Street Name TRACY ci 95304 <br /> ty Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 3940 NORTH TRACY BOULEVARD <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> TRACY CA 95304 <br /> PHONE#1 ExT. APN# LAND USE APPLICATION# <br /> (209 ) 407-9743 255-020-14 IPA-160049 <br /> PHONE#2 EXT BOS DISTRICT LOCATION CODE <br /> ( ) 5 <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR JULIO TINAJERO CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> MILESTONE ASSOCIATES IMAGINEERING,INC. 530 755-4700 <br /> HOME Or MAILING ADDRESS FAX# <br /> 1000 LINCOLN RD, STE H2O2 (530 )755-4567 <br /> CITY YUBA CITY STATE CA ZIP 95991 <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 ENVIRONMENTAI. HEALTH DI:PARTMGNT'hourly charges associated with this project <br /> or activity will be billed to me or my business as identified on this form. <br /> 11 also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN JOA(�UIN <br /> COUNTY 01-c/it7WICe Cbc%s,Stuar(II-CA, STA Il:and FEDI{RA laws. <br /> APPLICANT'S SIGNATURE: n:)rF: 3-21-22 <br /> PROPERTY/BUSINESS OWNER❑ O :R:1T'OR/ IANAG 1:1tERAITIIORIZEDAGENr® PROJECT MANAGER <br /> If APPLICANT is true the BILI.1.)Y;PART)'.proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE; INFORMATION: %Vhen applicable, 1, the owner or operator of the property located at the <br /> above site address, hereby authorize the release of any and all results, ('e0technical data an&or environmental/site assessment <br /> information to the SAN JOAQUIN COUNT)' ENVIRONMENTAL HEALTil DI:P:)R"I'MIiNT as soon as it is available and at the same time it is <br /> provided to me or my representative. p <br /> TYPE OF SERVICE REQUESTED:SEPTIC TANK PLAN REVIEW EC' NT <br /> COMMENTS: <br /> SSPJLr , �o �Sl��� �l�;vls f� b� �yvl�l�ed. s MAR29 ? <br /> �N JO �?? <br /> HEALTH COON ANT y <br /> RTME <br /> ACCEPTED BY: ��,���� EMPLOYEE#: l DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P/E: Ltl <br /> Fee Amount: �3 c� Amount Pai O Payment Date 2 <br /> Payment Type Invoice# Check# 1�� Received By:ayr <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />