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i <br /> SAN JOAQUI`"i'COUNTY ENVIRONMENTAL HEALTAPARTMENT�j <br /> ORIGINAL <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> p00 3� �Roo���l I <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME SB Gas and Market <br /> SITE ADDRESS 515W 11th Street Tracy 95376 <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 CA ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> ( 209 ) 607-0484 �Q3 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR �1 <br /> REQUESTOR Carl Wayne Henderson '56's-st,0 CHECK if BILLING ADDRESSi�I <br /> BUSINESS NAMEPHONE# 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 JO� <br /> COUNTY Ordinance Codes,Standards,STATE and FEDERAL laws. FC�i F,yr <br /> APPLICANT'S SIGNATURE: DATE: 7/20/15 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT® President h��•vl, GG `491 <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required Title `s <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, I,the owner or operator of the property located a4e <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: v l'�— l <br /> COMMENTS: JUL G i1 0 2015 <br /> Replaced S404 LEGACY latching controller under dispenser#3/8. <br /> E"ONMEIVT <br /> PEwhr/SER ENTH <br /> ACCEPTED BY: EMPLOYEE#: DATE: S <br /> ASSIGNED TO: , eay�� EMPLOYEE#: DATE: 6 t5 <br /> Date Service Completed (if already completed): SERVICE CODE: e- ��� PIE: <br /> Fee Amount: ?-,,--yo . Amount Pal 3 7�,Dd Payment Date 726 `S— <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />