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SAN JOAQUI UNTY ENVIRONMENTAL HEALT PARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> GDF `> ` 05 <br /> OWNER/ OPERATOR <br /> CHECK If BILLING ADDRESS❑ <br /> FACILITY NAME US Gasoline <br /> SITE ADDRESS 749 E MLK (Charter Ways Stockton 95206 <br /> Street Number 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 — 3 L f — 0 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR Carl Wayne Henderson CHECK If BILLING ADDRESS® <br /> BUSINESS NAME PHONE# EXT. <br /> HMC - Henderson Maintenance Company 209 467-7573 <br /> HOME or MAILING ADDRESS FAx# <br /> PO Box_ 31325 ( 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 FEDERAL laws. <br /> APPLICANT'S SIGNATURE: 01,10 -- DATE: 7 `2 7 <br /> PROPERTY/BUSINESS OWNER[] OPERATOR/MANAC ER ❑ OTHER AUTHORIZED AGENT Contractor <br /> If APPLIC AA'T is not the BILLING PARTY,proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1,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: � --("7— )41-P/ ^l 6- f ta--- PAY VES <br /> COMMENTS: Replaced 89 MLLD and operability tested. 1& <br /> auW cnu��Y <br /> SAIyENV RflNPR� ENS <br /> ACCEPTED BY: 10 L f v F d—ok EMPLOYEE#: 03-W DATE: 7 Z-7 0 Cy <br /> ASSIGNED TO: 0 AJ Fl, L EMPLOYEE#: e3( 7 DATE: ,-7 277 Q <br /> Date Service Completed (if already completed): 7/27/09 SERVICE CODE: Ij c PIE: <br /> Fee Amount: 3 f-5- Amount Paid 1 Payment Date el I -L /O <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />