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SAN JOAQUIN r'OUNTY ENVIRONMENTAL HEALTH PARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 1062-7 � –? S— �0 <br /> OWNER/O RATOR <br /> CHECK If BILLING ADDRESS❑ <br /> FACILITY NAME Penske Truck Leasing <br /> SITE ADDRESS 3663 P ersen Rd Stockton 95215 <br /> Street Number Direction Street Name Citv Zip Code <br /> HOME or MAILI G ADDRESS (If Different from ite Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 XT. APN# LAND USE APPLICATION# <br /> ( ) 7 O-- 2 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONT CTOR / SERVI E REQUESTOR <br /> REQUESTOR Carl Wayn Henderson CHECK if BILLING ADDRESS® <br /> BUSINESS NAME PHONE# EXT. <br /> HMC - H nderson Maintenance Compa y 209 467-7573 <br /> HOME or MAILING AD ESS FAX# <br /> PO Box 1325 ( 209 ) 465-4988 <br /> CITY Stockton STA CA ZIP 95213 <br /> BILLING ACKNOWLEDGEMENT: , the undersigned grope y or business o ner, operator or authorized agent of same, <br /> acknowledge that all site and/or projects cific ENVIRONMENT HEALTH DEPAR ENT hourly charges associated with this project <br /> or activity will be billed to me or my busines s identified this form. <br /> 1 also certify that 1 have prepared this application and that the work to be perfo ed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: t,.... DATE: 6/15/09 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑/HDEPARTM <br /> R AUTHORIZED AGENT® Contractor <br /> If APPLICANT is not the BILLING PARTY,proof ofon to sign is reliui ed Title <br /> AUTHORIZATION TO RELEASE INFORMATION: Whle, I, the ow erator of the property located at the <br /> above site address, hereby authorize the release of any ans, geote nical data a or environmental/site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL. HT as s n as it is ailable and at the same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: TANK RETROFIT - COLD ART A--,,7— <br /> COMMENTS: TCP/IP communications down. Printed AL RM HIST Y and ETUP. Coldstarted d restored ARCHIVED <br /> SETUP in TLS-350 to reestablished TCP/I communications., <br /> PAYMENT <br /> RECEIVED <br /> ACCEPTED BY: 0 v �� OAOUIN COU CMPLOYEE M 3 ZI DATE: ri G Gr <br /> ASSIGNED TO: F"t.-C HEN DEP R MPLOYEE#: ��i DATE: /! I I_ <br /> Date Service Completed (if already completed): 6/12/09 _ SERVICE CODE: P/E: <br /> Fee Amount: 3 l S. UJ Amount Paid 3�5, Payment Date <br /> Payment Type Invoice# Check# p OR� Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />