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SAN JOAQUGVJUNTY ENVIRONMENTAL HEALTH i�'ARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property f ACILITY16 `' SERVICE REQUEST# <br /> TRUCK STOP 50M3 (� <br /> ()wrtER/ PERATO PWT E H L E R S ` H CHECK BILLING ADDRESS <br /> FACILITY NAME COUNTRY MARKETPLACE <br /> WE ADDRESS 1789 W. CHARTER VIAY STOCKTON Q5206 <br /> S Hung Call zip Code <br /> HOME Or MAILING ADDRESS (H Different hom Site Address) SOwl <br /> NImMr SirpoiName <br /> CITY STATE zip <br /> PHOME#1 Em APN# LAND USE APPLICATION# <br /> ( 20)9 870 3508 <br /> PHONE#P Ex. SO$DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECKHBILLING AD RESS <br /> BUSINESS NAME PHONE# <br /> HOME or MAILING A RESS FAx# <br /> v 30 I ( ) . <br /> CITY STATE49 zip 3/ <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner, o Erato or authorized agent of same, <br /> acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hour y 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 TE and FEDERAL laws. 5X/4217/0 <br /> // / '7Z/ <br /> APPLICANT'S SIGNATURE �. T[�Q.G� DATE: 5Xlaa/O <br /> PROPERTY/BUStNESS OWNER C] OPERATOR/MANAGER;I OTHER AUTHORIZED AGENT❑ <br /> 1fAPPL1CANf is not the BiLL/NG PARTY.proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner o perato of the property located at the <br /> above site address, hereby authorize the release of any and all results, geotechnical data n or environrnentaUS/" ps��ment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and i ,Wt is <br /> provided to me or my representative. RE JNVattA TYPE OF SERVICEREQUESTED:COMMENTS: REPLACE LEAK DETECTOR, SUMP SENSOR, SPILL BUCKET TO �FAbOT�INTO COMPLIANCE PURSUANT TO SJCFHD INSPECTION REPORT OF �ND <br /> 5 APRIL, 04 CONDUCTED BY STEVEN SHIH N <br /> ACCEPTED BY: EMPLOYEE#: Zf DATE: CJ (3 <br /> ASSIGNED TO: S EMPLOYEE#: DATE: <br /> Date Service Completed (H already completed): SERVICE CODE: I 01E: <br /> Fee Amount: O Amount Paid � �j R, Dr' Payment Date S 3 o cF <br /> Payment Type Invoice# Check# Received By:�_ <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />