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SAN JOAQU*OUNTY ENVIRONMENTAL HEALTHIRPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> GDF Q S/LOO{, ZOO 1 <br /> OWNER/OPERATOR Chacko Thomas <br /> CHECK If BILLING ADDRESS <br /> FACILITYNAME Emil's Food Mart <br /> SITEADDRESS 1405 California St Escalon 95320 <br /> Street Number I Direction I Street Name city Zip Code <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 /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> I I <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR Carl Wayne Hendersonf p /cR'-7� ( CHECK If BILLING ADDRESS® <br /> BUSINESS NAME PHONE# ExT. <br /> APEC 209 1 943-3000 <br /> HOME or MAILING ADDRESS FAx# <br /> PO Box 55105 (209 ) 943-3003 <br /> CITY Stockton STATE CA ZIP 95205 <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 <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 FEDERAL laws. <br /> APPLICANT'S SIGNATURE: L---f �- /Z— DATE:5/25/11 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT® Techninian <br /> IfAPPLICANT is not the BILLING PARTY proof ofauthoriZatlon 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 to 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. MEMT <br /> TYPE OF SERVICE REQUESTED: REC <br /> COMMENTS: Replace 420 (L-4)annular space sensor. MAy <br /> Cow <br /> SA ENO RpNMEt`R E T <br /> H N\J1 DEPART <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: 2-&70 DATE: V <br /> Date Service Completed (if already completed): SERVICE CODE: 15,q I PIE: <br /> Fee Amount: Vo <br /> �� Amount Paid Z 3�(o DD Payment Date SZ <br /> Payment Type ✓ Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />