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SAN JOAQUW-OUNTY ENVIRONMENTAL HEALTHWARTMENT ORIGINAL <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> GDF <br /> OWNER/OPERATOR `J <br /> Chacko CHECK If BILLING ADDRESS <br /> FACILITY NAME Texaco- Escalon <br /> SITEADDRESS 1405 California St Escalon 95320 <br /> Street Number I Direction I Street Name city Zip Cotle <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE CA ZIP <br /> PHONE#1 EXT' APN# LAND USE APPLICATION# <br /> 1 209 ) 8387674 a;?7a 70 3 J <br /> PHONE#2 ExT. BOS Di CT LOCATION CODE <br /> I I SO <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR Carl Wayne Henderson CHECK If BILLING ADDRESS® <br /> BUSINESS NAME PHONE# Ezr' <br /> Service Station Testing- SST INC/CSLB 962520 209 465-5577 <br /> HOME or MAILING ADDRESS FAX# <br /> PO Box 31465 (209 ) 465-4988 <br /> CITY Stockton STATE CA ZIP 95213 <br /> BILLING ACKNOWLEDGEMENT: 1, 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,Standards,STATE and FED RAL laws. <br /> APPLICANT'S SIGNATURE:n I L« / DATE: 5/14/15 <br /> PROPERTY/BUSINESS OWNER[3 OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT® President <br /> if APPLICANT is not The B/LL/NG 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 <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br /> information t0 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. Pq <br /> "JFTYPE OF SERVICE REQUESTED: U'� CE <br /> COMMENTS: Replaced 420 sensor at L-4 (tank annular) - PER EHD inspection dated 5-6-2015 AMY 15 <br /> SqN j Z01 <br /> H& LTEJVry gfR�Aj <br /> ACCEPTED BY: EMPLOYEE#: DATE: A5 .119-6 <br /> ASSIGNED TO: EMPLOYEE#: DATE: 't?.((�' 1 I <br /> Date Service Completed (if already completed): 5/13/15 SERVICE CODE: P I E: JJ (7 <br /> Fee Amount: Amount P ' Payment Date <br /> Payment Type Invoice# Check# ��� Recei ed By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />