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02/24/2012 FRI 15:04 FAX 20 ^683433 SJC EHJft 2001 <br /> ********************* <br /> *** FAX TX REPORT *** <br /> ********************* <br /> TRANSMISSION OK <br /> JOB NO. 4598 <br /> DESTINATION ADDRESS 94654988 <br /> PSWD/SUBADDRESS <br /> DESTINATION ID <br /> ST. TIME 02/24 15:01 <br /> USAGE T 03' 36 <br /> PGS. 4 <br /> RESULT OK <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Hospital/Generator s STS oo&q O <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 Ci 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 /> ( D <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR Carl Wayne Henderson CHECK if BILLING ADDRESS <br /> BUSINESS NAME Service Station Testing-SST INC PHONE# L EXT. <br /> 209 465-5577 js <br /> HOME or MAILING ADDRESS FAx# <br /> PO Box 31465 (209 ) 465-4988 <br /> CITY Stockton STATE CA zip 95213 <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner,operator or authorized agent of same, <br /> acknowledge that all site and/or project specific ENVIRONMENTAL HEALTii 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 FEDDE�aws. <br /> APPLICANT'S SIGNATURE: C".0 1-• f^' DATE: 12/16/11 <br /> PROPERTY IBUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTNORIzF,DAGENT President - <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 to the SAN JOAQUIN COUNTY ENVIRONMENTAL FIEALT1i 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. RECEIVED <br />