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SAN JOAQU OUNTY ENVIRONMENTAL HEALT DEPARTME <br /> SERVICE REQUEST ORIGINAL <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> FGDF ?J$71',> _`7.9.00700'?/ <br /> OWNER/OPERATOR <br /> CHECK if BILLING ADDRESS E] <br /> FACILITY NAME US Gasoline <br /> SITE ADDRESSEMLK (Charter Way) Stockton 95206 <br /> Street Number I Direction 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 /> ( 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 /> BUSINESS NAME PHONE# EXT. <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: 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: e.1 L, /L— DATE: 7/18/14 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT® President <br /> IfAPPL/CANT is not the B/cc/NG PARTP 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. PAY <br /> TYPE OF SERVICE REQUESTED: S ` �( -p j CEI <br /> COMMENTS: ATG CRASH -Alarm History lost. JUL2 r 2��4 <br /> TLS-350 dead battery. SAN <br /> Replaced battery & COLDSTARTED. ENV RO OIJN <br /> "E <br /> Al DEPARTME <br /> ACCEPTED BY: r i I EMPLOYEE#: DATE: 7/2—i (c( <br /> ASSIGNED TO: Rt - EMPLOYEE#: DATE: —7/21 i <br /> Date Service Completed (if already completed): 7/18/14 SERVICE CODE: t l '$ P 1 E: ?'jo <br /> Fee Amount: j 7 oa' Amount Paid 7S(�� Payment Date 7 <br /> Payment Type Invoice# Check# I X02 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />