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SAN JOAQU*OUNTY ENVIRONMENTAL HEALTHOPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> GDF s Af;o o 6�/�j <br /> OWNER/OPERATOR Balaji S. Angle CHECK if BILLING ADDRESS❑ <br /> FACILITY NAME Ripon Shell <br /> SITE ADDRESS 341 E Main St Ripon 95366 <br /> Street Number Direction I 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 ) 599-4454 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR Carl Wayne Henderson 203296 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 /> CIN 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 JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: C,—,p DATE: 11/27/12 <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT® President <br /> If APDL/CANT is not the BILLING PARTY,proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, I,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: Replace 4 existing Gilbarco Advantage dispensers with 4 NEW Gilbarco Encore 300 dispensers utilizing <br /> BRAVO CONV-62000 conversion frames. No changes below the shear valve are expected. yoe <br /> N0� 2 coo" <br /> ACCEPTED BY: EMPLOYEE#: DATE: v��Q MENS <br /> ASSIGNED TO: A4UV L) EMPLOYEE#: DATE: New <br /> Date Service Completed (if already completed): SERVICE CODE: P I E: <br /> Fee Amount: 5' ` Amount Paid a j'7�, (� Payment ate () (?,q12j <br /> Payment Type ✓ Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />