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• SAN.TOAQ U11� COUNTY ENVIRONMENTAL HEALTHtEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> GDF LO7 <br /> OWNER/OPERATOR Tran CHECK if BILLING ADDRESS <br /> FACILITY NAME Marigold Shell <br /> SITE ADDRESS 6131 Pacific Ave Stockton 95207 <br /> Street Number I Direction Street Name city Zip 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 ) 244-8885 0 '7 7 L' t;q l z) <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR Carl Wayne Henderson 303694 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 /> 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: / L-,—- H� DATE: 3/27/13 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT® President <br /> If APPL/CANT 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 aPAi is <br /> provided to me or my representative. R - ••,C <br /> TYPE OF SERVICE REQUESTED: TANK RETROFIT MAP 2 <br /> COMMENTS: H-8 alarm. CPU battery dead requiring coldstart. SAN <br /> EJOANVIROME COON <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): 3/27/13 SERVICE CODE: 031 P 1 E: <br /> Fee Amount: 3'1 Amount Paid 375-e2D Payment Date <br /> Payment Type ✓ Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />