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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or PropertyFACILITY ID # SERVICE REQUEST # <br /> Cardlock S oo3q ( Z to , ; <br /> OWNER / OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> 2825 Railroad Ave . Ceres CA . 95307 <br /> SITE ADDRESS 4733 S 1 4733 S . Hwy 99 Frontage Rd . Stockton 95206 <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 ZIP <br /> PHONE #1 EXT, APN # LAND USE APPLICATION # <br /> ( ) ki CO) Soo 0 02, <br /> PHONE #2 EXT , BOS DISTRICT LOCATION CODE <br /> ( 77 F , I <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> Bonnie Garber <br /> BUSINESS NAME PHONE # EXT, <br /> Donlee Pumn Company 209 537-9396 <br /> HOME Or MAILING ADDRESS FAX # <br /> 2825 Railroad Ave . ( 209 ) 537-9398 <br /> CITY STATE ZIP <br /> Ceres , CA. 95307 <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 or <br /> activity will be billed to me or my business as identified on this form . <br /> 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 : '/ � /[� �Oc/ r <br /> PROPERTY / BUSINESS OWNER ❑ OPERATOR / MR ❑ o OTHER AUTHORIZED AGENT ❑� Admin . <br /> If APPLICANT is not the BILLING PARTY, roof 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 above <br /> site address , hereby authorize the release of any and all results , geotechnical data and/or environmental/site assessment information <br /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the same time It Isplarovided to me Or <br /> my representative . <br /> TYPE OF SERVICE REQUESTED : aiesel-Spill Bucket replacemerlt CF 4Z1V214 <br /> COMMENTS : Install new OPW 2200 Series Diesel Bucket due to tears at top of bucket Jul <br /> 23 <br /> 044 %JO� Qu/1V c ?o2o <br /> TjyO pqR '4 N <br /> T <br /> ACCEPTED BY: � � ��\/Q��� EMPLOYEE # : DATE : <br /> ASSIGNED TO : �u� r O EMPLOYEE # : DATE : 2� <br /> Date Service Completed ( if already completed) : 44 SERVICE CODE : P IE: <br /> Fee Amount: ( C'� Amount Pai TS(� v Payment Date 7 23 <br /> Payment Type Invoice # Check # 39621 Received By : <br /> EHD 48-02-025 SR FORM (Golden Rod) <br /> 07/ 17/08 <br />