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SAN JOAQUIN r'OUNTY ENVIRONMENTAL HEALTF T)EPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> GDF <br /> OWNER/OPERATOR Kiv CHECK if BILLING ADDRESS❑ <br /> FACILITY NAME "FLAG CITY CHEVRON" <br /> SITE ADDRESS 6421 1 Capitol Ave Lodi ]T5242 <br /> Street Number Direction Street Name CIty Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street NumberT Street Name <br /> CITY STATE CA ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> ( 209 ) 481-8180 Z C: Z <br /> PHONE#2 EXT. BOS DISTRICT LOCATIN CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR Carl Wayne Henderson <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME Service Station Testing -SST INC PHONE# EXT. <br /> 209 465-5577 <br /> HOME or MAILING ADDRESS 3O4 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: C1--4 c--- DATE: 8/26/13 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT® President <br /> If APPLICANT is not the BILLING PARTY,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. <br /> TYPE OF SERVICE REQUESTED: u,( <br /> COMMENTS: Replace defective Diesel annular sensor (L-4) RECEIVED <br /> AUG 2 S 2013 <br /> SAN JOAQUIN COUNTY <br /> ENVIROMEN TAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: N�( L� EMPLOYEE#: DATE: -2 <br /> ASSIGNED TO: S EMPLOYEE#: 0 L L DATE: <br /> Date Service Completed (if already completed): 8/26/13 SERVICE CODE: j PIE: <br /> Fee Amount: 3-/ S __ _---- -- Amount Paid S�—o�_ Payment Date �g 3 <br /> Payment Type VInvoice# Check# Received By <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />