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SAN JOAQUD*UNTY ENVIRONMENTAL HEALTIOPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> GDF <br /> OWNER I OPERATOR CHECK If BILLING ADDRESS <br /> FACIUTYNAME US Gasoline <br /> SITE ADDRESS 7,(-q E MLK (Charter Way) Stockton 95206 <br /> SVeet Number Direction Street Name CI ZI Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE CA ZIP <br /> PHONE#1 Ex . APN# LAND USE APPLICATION# <br /> ( 209 ) 465-8979 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR Carl Wayne Henderson 14127 CHECK if BILLING ADDRESS® <br /> PHONE# ExT. <br /> BUSINESS NAME 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: 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 andFEDERAL <br /> APPLICANT'S SIGNATURE: 1�1DATE: 7/18/14 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT® President <br /> I,f APPLICANT is not the BILLING 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 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. <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: ATG CRASH -Alarm History lost. <br /> TLS-350 dead battery. <br /> Replaced battery &COLDSTARTED. <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): 7/18/14 SERVICE CODE: PIE: <br /> Fee Amount: Amount Paid Payment Date <br /> Payment Type <br /> Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> ocviccn 11H711nn4 <br />