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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> ype of Business or Property FACILITY ID# SERVICE REQUEST# <br /> GDF S'�06 (,�)--7 9-90 <br /> OWNER/OPERATOR KIv CHECK if BILLING ADDRESS❑ <br /> FACILITY NAME "FLAG CITY CHEVRON" <br /> SITEADDRESS 6421 Capitol Ave Lodi 95242 <br /> Street 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 ExT• APN# LAND USE APPLICATION# <br /> ( 209 ) 481-8180 <br /> PHONE#1 ExT BOS DISTRICT LOCATQN CCODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR Carl Wayne Henderson <br /> CHECK If BILLING ADDRESS® <br /> BUSINESS NAME PHONE# ExT. <br /> Service Station Testing -SST INC 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: �( ' �-- Gt��� DATE: 8/26/13 <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT® President <br /> IfAPPL1CANT 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: `l fa PAYMENT' <br /> COMMENTS: Replace defective Diesel annular sensor(L-4) RECE111VE ► <br /> AUG 28 2013 <br /> SAN JOAQUIN COUNTY' <br /> ENVIROMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: 24 70 DATE: <br /> ASSIGNED TO: S ~ EMPLOYEE#: i cF - •, DATE: <br /> Date Service Completed (if already completed): 8/26/13 SERVICE CODE: PIE: �3&S, <br /> Fee Amount-A- -, cam'" -- Amount Paid �s'o+� Payment Date 8e �g 13 <br /> Payment Type Invoice# Check# Received By• <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />