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SAN JOAQUUV,•LINTY ENVIRONMENTAL HEALTH*ARTMEN ORIGINAL <br /> hf SERVICE REQUEST �`. <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> GDF -VP-0 0700'F/ <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME US Gasoline <br /> SITE ADDRESS Yj E MLK (Charter Way) Stockton 95206 <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 En. APN# LAND USE APPLICATION# <br /> .( 209 ) 465-8979 <br /> PHONE#2 ExT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> R.EQUESTOR Carl Wayne Henderson 14127 CHECK If BILLING ADDRESS® <br /> BUSINESS NAME PHONE# EXT. <br /> Service Station Testing -SST INC/CSLB 962520 <br /> HOME or MAILING ADDRESS - FAX# <br /> PO Box 31465 (209 ) 465-4988 <br /> CITY Stockton STATE CA ZIP 95213 <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: w. DATE: 7/18/14 <br /> PROPERTY/BUSINESS OWNERO OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT 10 President <br /> IfAPPLICANT is not the BILLINGPARTY 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 to the SAN JOAQUIN COUNTY ENVIRONN ENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. !� j� pAY <br /> TYPE OF SERVICE REQUESTED: s l (Z4, Y'D I 'C EC <br /> 1EIV <br /> COMMENTS: ATG CRASH -Alarm History lost. L 21 1014 <br /> TLS-350 dead battery. S-41, <br /> ARjOqO <br /> eplaced battery &COLDSTARTED s �NH4 TNHE M <br /> ACCEPTED BY: (_ L EMPLOYEE#: DATE: <br /> ASSIGNED TO: Rf EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): 7/18/14 SERVICE CODE: ( Ll '$ I P/E: Z v <br /> Fee Amount: P'm Amount Paid Payment Date W/ <br /> Payment Type Invoice# Check# got Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />