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I I . I <br /> SAN JOAQUINPOUNTY ENVIRONMENTAL HEALTH AARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID =SERVICE REQUEST# <br /> OWNER/OPERATOR CHECK if_BILLING ADDRESS 0 <br /> FAcluTy NAME SB Gas and Market <br /> Tracy Ci =95376 <br /> V1 z! <br /> SITE ADDRESS 515 1 1��,' - Code <br /> .' ��11�th Street Tracy <br /> Street Direction <br /> St Name <br /> HOME or MAILING ADDRESS (if Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE CA zip <br /> PHONE#t Ex'r. APN# LAND USE APPLICATION# <br /> ( 209 ) 607-0484 <br /> BOS DISTRICT <br /> PHONE#2 <br /> ExT. 1-LOCATION CODE <br /> CONTRACTOR SERVICE REQUESTOR <br /> REQUESTOR Carl Wayne Henderson 66's-S&O CHECK if BILLINGADDRESS <br /> i-' PHONE# Ext. <br /> BUSINESS NAME <br /> Service Station Testing-SST INC CSLB 962520 ( 209 ) 465-5577 <br /> FAx# <br /> HOME or MAILING ADDRESS (209 ) 465-4988 <br /> P0 Box 31465 <br /> STATE CA ZIP 95213 <br /> CITY Sto kPo"If <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 /> 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: DATE: 7/20/15 <br /> PROPERTV/BUSINESS OWNER 13 OPERATOR/MANAGER 13 OTHER AUTHORIZED AGENT® President <br /> If APPLICANT is not the BILLING PAR 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 at the same time it is <br /> provided to me or my representative. <br /> �EREQUE ED' <br /> Vic <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS:TS.. <br /> COMMENTS: <br /> Replaced S400 <br /> 4 LEGACY latching controller under,dispenser#7/8 <br /> ACCEPTED BY: EMPLOYEE#: I DATE: <br /> EM OYEE#' DATE: <br /> ­ <br /> EMPLOYEE#: DATE: <br /> ASSIGNED TO: SERVICE CODE: PIE: <br /> Date Service Completed (if already completed): <br /> Fee Amount: Amount Paid Payment Date <br /> I ] # <br /> Payment Type Invoice# Check# Received By: <br /> SIR FORM(Golden Rod) <br /> EHD 48-02-025 <br /> REVISED 11/17/2003 <br />