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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT ONGINAL <br /> SERVICE REQUEST �---' <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> GDF FA (7e 0 5,2 o 6) 413k � <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS❑ <br /> FACILITY NAME J&L Market <br /> SITE ADDRESS 8115 S EI Dorado St Stockton CA <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 95231 ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> ( 209 ) 982-0897 1 C13 1 +} o �3 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR Carl Wayne Henderson 404911 CHECK if BILLING ADDRESS® <br /> BUSINESS NAME PHONE# EXT. <br /> Service Station Testing -SST INC/CSLB 962520 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: �� �y— DATE: 4/4/14 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT® President <br /> ff 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. PAYAO <br /> TYPE OF SERVICE REQUESTED: d S CSI VE <br /> COMMENTS: COLDSTART: SAN 0 8 ?014 <br /> Veeder-Root H-8 crash. Replaced battery, COLDSTART& restored from archive. HEAENV nOQ qUN <br /> H 4EPARTMrNT <br /> ACCEPTED BY: EMPLOYEE M -26-7U DATE: <br /> ASSIGNED TO: J. EMPLOYEE M / L 2( DATE: Y <br /> Date Service Completed (i already completed): 4/3/14 SERVICE CODE: r PIE: Gl� <br /> Fee Amount: 3� Amount Pai 3 p Payment Date g <br /> Payment Type Invoice# Check# I -��� Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />