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SAN JOAQUI1, COUNTY ENVIRONMENTAL HEALTH _ PARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property <br /> FACILITY ID# SERVICE REQUEST# <br /> GDF <br /> OWNER/OPERATOR Vic Judge CHECK if BILLING ADDRESS <br /> FACILITY NAME ABC Food Mart-Valero Mr Cafe <br /> SITE ADDRESS -113 <br /> N EI Dorado St Stockton 9�20 <br /> Street Number Direction <br /> Stree=Name Cit 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 /> (X ) <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR Carl Wayne Henderson CHECK if BILLING ADDRESS® <br /> PHONE# EXT. <br /> BUSINESS NAME APEC J209 943-3000 <br /> HOME Or MAILING ADDRESS FAX# <br /> PO Box 55105 ( 209 ) 943-3003 <br /> CITYStockton STATE CA ZIP 95205 <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 DF.PARTMENI,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 laws. <br /> APPLICANT'S SIGNATURE: (, �" r DATE: 5 <br /> PROPERTY/BtISINESS OWNER❑ OPERATOR/MANAGER <br /> ❑ OTHER AUTHORIZED AGENT 10 Techninian <br /> /f APPLICANT is not the BILLING PARTY,proof of authorization to sign is required Title <br /> ALITHORIZATION 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: <br /> COMMENTS: Repairs/Adjustments per UST Inspection Report dated 4/27/2011: <br /> 17: Adjust Diesel hold pressure for PLLD shutdown. <br /> 18 &45: Replace gackets on fill sumps&buckets for water tightness. (parts ordered) <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> EMPLOYEE#: DATE: <br /> ASSIGNED TO: <br /> Date Service Completed (if already completed): SERVICE CODE: P E: <br /> Fee Amount: Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />