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SAN JOAQUI,. k:OUNTY ENVIRONMENTAL HEALTH ,,,:PARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 0 ' � Z bD <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADORE S <br /> FACILITY NAME Freeway Shell <br /> SITE ADDRESS 7700 E Moreland Ct Stockton 95212 <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 ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> ( ) <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR Carl Wayne Henderson 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: 1, 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 /> 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 /> COUNTY Ordinance Codes,Standards, STATE and FEDERAL flaws. <br /> APPLICANT'S SIGNATURE: Caj w f.L-'� DATE: <br /> PROPERTY/BtIS1NESS OWN ER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT® President <br /> /f APPLICANT is not the BILLING PARTY,proof Of authorization t0 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: r g= <br /> COMMENTS: Replace 1-6: Annular Sensor DSL/91 Tank AUG _8 2012 <br /> SAN RONMENTALTY <br /> HATH DEPARTMENT <br /> ACCEPTED BY: CA <br /> EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): 8/8/12 SERVICE CODE: P/E: U <br /> Fee Amount: , Amount Paid 3 7� �; L Payment Date I Z� <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />