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f � <br /> SAN JOAQU1*1OUNTY ENVIRONMENTAL HEALTHOPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# nnSERVICE REQUEST# <br /> GDF 4a 45 t—� 07 <br /> OWNER/OPERATOR Steve Azevedo /_ Gj CHECK If BILLING ADDRESS O <br /> FACILITYNAME Knife River <br /> SITEADDRESS 655 W Clay St 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 CA ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> ( 209 ) 948-0302 1 �7 f�2o o <br /> PHONE#2 ExT• BOS DISTRICT LOCATION CODE <br /> 1 ) <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 /> 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: CAS t—- / DATE: 7/15/13 <br /> PROPERTY/BUSINESS OWNER[3 OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT® President <br /> If APPL/CANT 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 /> COMMENTS: Replaced damaged POWER SUPPLY at Veeder-Root TLS-300 discovered during annual mo <br /> on 7-12-2013. ED <br /> JUL ] 6 2013 <br /> SAN JOAQUIN COUN <br /> ly <br /> ENVIROMENTAL <br /> ACCEPTED BY: �t� T 1 �� EMPLOYEE#: DATE: "7 f EN <br /> ASSIGNED TO: '\' <br /> ✓�• EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): 7/15/13 SERVICE CODE: ' 1 s( PIE: <br /> (J <br /> Fee Amount: 75- 0' Amount Paid 3790 Payment Date 7&1-113 <br /> Payment Type Invoice# Check# 0113 3 Received By <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />