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SAN JOAQU OUNTY ENVIRONMENTAL HEALTH PARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />SERVICE REQUEST # <br />GDF <br />PHONE # EXT. <br />209 465-5577 <br />HOME or MAILING ADDRESS <br />PO Sox 31465 <br />OWNER/ OPERATOR <br />FAx# <br />( 209 ) 465-4988 <br />Steve Azevedo <br />CHECK if BILLING ADDRESS❑ <br />FACILITY NAME Knife River <br />ASSIGNED TO: <br />SITE ADDRESS 655W <br />EMPLOYEE #: <br />Clay St <br />I <br />DATE: <br />Stockton <br />95206 <br />Street Number <br />Direction <br />P / E: /r <br />V <br />Street Name <br />city <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />ate YFI13 <br />Payment Type <br />Invoice # <br />Street Number <br />Street Name <br />CITY <br />STATE CA ZIP <br />PHONE #1 EXT. <br />APN # <br />LAND USE APPLICATION # <br />PHONE #2 EXT. <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR Carl Wayne Henderson <br />303432 <br />CHECK if BILLING ADDRESS <br />BUSINESS NAME <br />Service Station Testing -SST INC <br />COMMENTS: Replaced defective MLLD. <br />PHONE # EXT. <br />209 465-5577 <br />HOME or MAILING ADDRESS <br />PO Sox 31465 <br />ACCEPTED BY: <br />FAx# <br />( 209 ) 465-4988 <br />CITY Stockton <br />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 FEDE AL laws. <br />APPLICANT'S SIGNATURE: r-t�( LL - DATE: 1/6/13 <br />PROPERTY/ BUSINESS OWNER❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT ® President <br />If APDL/CANT 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 to 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 defective MLLD. <br />IF <br />ACCEPTED BY: <br />EMPLOYEE #: <br />DATE: <br />ASSIGNED TO: <br />EMPLOYEE #: <br />DATE: <br />Date Service Completed (if already completed): 1/6/03 <br />SERVICE CODE: <br />P / E: /r <br />V <br />Fee Amount: S ' <br />Amount Paid <br />3W.6,) <br />Payment <br />ate YFI13 <br />Payment Type <br />Invoice # <br />Check # 1A&P' <br />Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />