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SAN JOAQUiw COUNTY ENVIRONMENTAL HEALTH i1EPARTMENT <br />SERVICE REQUEST J <br />Type of Business or Property <br />FACILITY ID # <br />CHECK If BILLING ADDRESS <br />ERVICE REEQUEST # <br />PHONE # EXT. <br />(209) 467-7573 <br />36'o/ <br />FEB 0 9 2009 <br />y <br />OWNER/ OPERATOR <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />El <br />Lawrence <br />STATE ZIP <br />CHECK If BILLING ADDRESS <br />FACILITY NAME Arco <br />Ci J� Z <br />DATE: 49 <br />SITE ADDRESS 130 S WIISO <br />Way <br />DATE: !t 0 <br />Date Service Completed (if already completed): 2/6/09 <br />SERVICE CODE: 19 k <br />Street Number <br />Direction <br />Street Name <br />City <br />Zip Code <br />HOME Or MAILING ADDRESS (If Different from Site Address) <br />Invoice # <br />Check # <br />1 O 2 <br />Received By: tyTr <br />Street Number <br />Street Name <br />CITY <br />STATE ZIP <br />PHONE #1 EXT. <br />APN # <br />LAND USE APPLICATION # <br />1 ) (209) 466-9516 <br />SS — <br />GZ C, -- <br />PHONE #2 EXT. <br />BOS DISTRICT 7 <br />LOCATIQN CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />Carl W Henderson <br />CHECK If BILLING ADDRESS <br />BUSINESS NAME <br />HMC -Henderson Maint Co <br />PHONE # EXT. <br />(209) 467-7573 <br />HOME or MAILING ADDRESS <br />FEB 0 9 2009 <br />FAX <br />PO Box 31325 -Stockton, CA 95213 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />( 209 ) 465-4988 <br />CITY <br />STATE ZIP <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 ENVIRONMEN IAL HFAI.Tu DI:PAR FMEN l hourly charges associated with this project <br />or activity will be billed to me or my business as identified on this form. <br />1 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 />COri IN IY 01-dln(PICL' Coc%.i, ,S'landah cLe, SA11 and H I)II[R/AI, laws. <br />APPLICANT'SSIGNATURE: Cwt° L--- DATE: Z "-7 <br />PROPERTY / 13USINESS OWNER ❑ OPERA roR / Nl.%N:u:ER ❑ O'I'IIF.R Al1'I'HORIZED AGENT' <br />fffPPl.u'.I,vr is not l/re B11.L1Nc PAR11, 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 .IOA()I IIN OWNrY ENVIRONMENTAL HI:;I �III DiAIAR'IMENI- as soon as it is available and at the same time it is <br />provided to me or my representative. Ltd t -� / 0( ,L (y 1_ fm, a— <br />TYPE OF SERVICE REQUESTED: 1 E-P.A, e <br />PAYMENT <br />COMMENTS: <br />Work performed 2/6/09. <br />FEB 0 9 2009 <br />Performed operability test of PLLD prior to placing site in service. <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />ACCEPTED BY: O L L` tq <br />T <br />EMPLOYEE #: <br />Ci J� Z <br />DATE: 49 <br />ASSIGNED TO: �� ^J <br />EMPLOYEE #: <br />DATE: !t 0 <br />Date Service Completed (if already completed): 2/6/09 <br />SERVICE CODE: 19 k <br />P / E. z3O�i <br />Fee Amount: 3 i 5 <br />Amount Paid `s _ <br />Payment Date <br />2 �j 1 6.9 <br />Payment Type l� <br />Invoice # <br />Check # <br />1 O 2 <br />Received By: tyTr <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />