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SAN JOAQUINCOUNTY ENVIRONMENTAL HEALTH PEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />CHECK if BILLING ADDRESS <br />FACILITY ID # <br />ASSIGNED <br />SERVICE REQUEST # <br />GDF <br />� <br />HOME or MAILING ADDRESS <br />FAX# <br />PO Box 55105 <br />' <br />PaymentDate[l 'Fil <br />( 209 ) 943-3003 <br />CITY Stockton <br />OWNER / OPERATOR Mr. Angle <br />Received By: <br />CHECK if BILLING ADDRESS 13 <br />FACILITY NAME Ripon Shell <br />SITE ADDRESS 341 <br />E <br />Main St <br />I <br />Ripon <br />95366 <br />Street Number <br />Direction <br />Street Name <br />C ity <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Street Number <br />Street Name <br />CITY <br />STATE CA <br />ZIP <br />PHONE #1 EXT. <br />APN # <br />LAND USE APPLICATIONIV <br />PHONE #2 EXT. <br />BOS DISTRICT <br />LOCATION E <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR Carl Wayne Henderson <br />CHECK if BILLING ADDRESS <br />BUSINESS NAME <br />APEC <br />ASSIGNED <br />PHONE# EXT. <br />�70 <br />� <br />209 1 943-3000 <br />HOME or MAILING ADDRESS <br />P I E: <br />FAX# <br />PO Box 55105 <br />' <br />PaymentDate[l 'Fil <br />( 209 ) 943-3003 <br />CITY Stockton <br />STATE CA ZIP 95205 <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: (f•,_.P . N� �"'" DATE: 1/18/11 <br />PROPERTY/ BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT® Technician <br />If APPLICANT is not the BILLING PARTY, 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 t0 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 />EV <br />TON <br />COMMENTS: Upgrade Veeder-Root software per CARB. From v102 to v103. Includes coldstart and hose mapping. <br />R <br />r.100 <br />SAE <br />ACCEPTED BY: <br />EMPLOYEE #: S / <br />DATE: <br />ASSIGNED <br />�70 <br />� <br />Date Service Completed (if already completed: <br />SERVICE CODE: j <br />P I E: <br />Fee Amount: 3� . <br />Amount Paid 3 (o, D <br />' <br />PaymentDate[l 'Fil <br />Payment Type <br />Invoice # <br />Check # D vS— <br />Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />