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W <br />SAN JOAQViiN C0UNTY ENVIR0NMENTAL,HEALT I PARTMENT <br />. S RVhCE+ tEOUEST <br />Type of Business or Rrop>srty • W FACILITY I . � # " <br />t • SER111C REQUEST #,.rt ` <br />° <br />' , , • .GDF ... ,. , . ��- � � O l�-i <br />�. <br />OWNER /:OPERATOR' 6 <br />. Auburn 7-7q Inc - - <br />CHECK If BILLING QREssa <br />, <br />#=uTY NAME, Arco • Mossdale <br />HOME or LWUNG ADDRESS <br />PO Box 3'1465. <br />.• <br />ACCEPTED BY: <br />FAX # <br />( 209 ) 465-4988 <br />SITE ADDREsq , <br />St0`Ckton <br />Mossdale Rd. ;: ' , , �.. <br />Lathrop <br />95330 .. <br />«�' Street Number <br />n <br />SERVICE CODE' n <br />P 1 L, <br />Fee Amount:` <br />Amount Paid <br />HOME or MAluNG ADDRESS (ff DWerent Vom Site Address) <br />Paymeh! Date <br />,M <br />CITY <br />STATS CA �lPLF <br />p <br />PHONE 1� EXT. APN'# + - <br />LAND USE APPLICATION # <br />( 209 # �� 0 ✓wwv <br />PtIONE EXT <br />BOS DISTRICT L.ocanON CODE <br />. , skDX.V'.Ter&1rJFAL4I AVA T a M!A 31 a] is Mt.sK91: <br />RI'�QUESTOR ' <br />'� i -- • --- -- <br />Carl Wayne Henderson. ` ` <br />. <br />C1&'M If BILLING ADDRESS_at <br />BusiNess NAME <br />Service Station Testing - SST INC / CSLB 962520 <br />Input Module & Transformer after POWER SPIKE damage. <br />PHONE #` <br />465-5677 <br />HOME or LWUNG ADDRESS <br />PO Box 3'1465. <br />.• <br />ACCEPTED BY: <br />FAX # <br />( 209 ) 465-4988 <br />CITY: c <br />St0`Ckton <br />STATE CA ZIP 95213 <br />s <br />MLLING AClkNQ_*_j EDGEMENT: I, =thd undersigriQd property or btisine�is owner, operator or authorized agent of same, `• <br />acknowledge that all siie and/or. project Specific BNVIRONME.NTAL HEALTH DEPARTMENT hourly charges associated, with this project <br />or activity. will•be billed to me -oar my business as identified on this form. <br />• <br />li also certify. that I have prepared this application $IId that the work to be performed will be' done in accordance with all SAN JOAQUIN <br />CoUN•i'Y Or&nance Codes, Standards, STATE and PEDL)tAL laws. <br />11/27)13 <br />. APRLICANT'5 SfGNATURE: � E • „e,�(� �...; . /y ' DATE: <br />PROPERTY / BUSINESS OWNER❑ OPERATOR / MANAGER [3 ' OTHER AUTHORUMD AGENT ® President <br />If APPLICANT isnot the ML_Z VG PA.BZi,P100f of authOrkadOn to sign iS requh-ed Tf tte : <br />AU'FHO TI N N : Wheh dpplicaMe,1, the owner or operator of the property located at the <br />above •,site address, hereby. authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br />information to the'SAN JOAQUIN COUNTY:,ENVIRONMENTAL 14EALTH DEPAPTmFNT as soon as it is available and at the same time it is <br />provided to me or my representative. <br />EHD 48-02-026SR FORM (Golden Rod) <br />REVISED 11/17/,00$ r� <br />a <br />�I A: <br />w .� <br />TYPE OF SERVICE REQUESTED: ' <br />COMMENTS:: Replaced damaged TLS -350 Power Supply, A1C <br />Input Module & Transformer after POWER SPIKE damage. <br />*grammed and checked'operatrion. <br />.• <br />ACCEPTED BY: <br />EMPLOYEE #' <br />DATE ' <br />ASSIGNED TO: <br />EMPLOYEE <br />Date Service ;ckmpleted (ff already Compleisd): 11p2 j�13 <br />n <br />SERVICE CODE' n <br />P 1 L, <br />Fee Amount:` <br />Amount Paid <br />'' <br />Paymeh! Date <br />,M <br />.Payment TCype <br />Invoice #. <br />ChecK# <br />Received i}y: <br />EHD 48-02-026SR FORM (Golden Rod) <br />REVISED 11/17/,00$ r� <br />a <br />�I A: <br />w .� <br />