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1 <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH I PARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Hospital/Generator Sg00&`t os--S- <br /> OWNER <br /> .s-S - <br /> OWNER/OPERATOR Dameron Hospital CHECK if BILLING ADDRESS <br /> FACILITY NAME Dameron Hospital Plant Operations and Maintenance ATTN: Jacob Wiebe/Director <br /> SITE ADDRESS 525W Acacia Street Stockton 95203 <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 ) 401-4506 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR Carl Wayne Henderson 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 /> CITY 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 /> 1 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 i--• i'�rI DATE: 12/16/11 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT® President <br /> If APPLICANT 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 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 /> COMMENTS: Install MLLD on diesel STP for existing Generator system. RECEfVED <br /> DEC 2 0 2011 <br /> &".}OAQUW COUNTY - <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: LZ CLL EMPLOYEE#: R(�S— DATE: <br /> ASSIGNED TO: We atm EMPLOYEE#: g DATE: <br /> Date Service Completed (if already Completed): SERVICE CODE: Cl P 1 E: 2-3v� <br /> Fee Amount: Ofs Amount Paid -1 Payment Date �Z 0 <br /> Payment Type Invoice# Check# t Receive B . <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br /> i <br />