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SAN JOAQUIPCOUNTY ENVIRONMENTAL HEALTAPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />SERVICE REQUEST # <br />o & (04 <br />OWNER / OPERATOR Steve Azevedo <br />CHECK if BILLING ADDRESS <br />FACILITY NAME Knife River Corporation <br />SITE ADDRESS 655 <br />Street Number <br />W <br />Direction <br />Clay St <br />Street Name <br />Stockton <br />city <br />95206 <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Street Number <br />Street Name <br />CITY <br />STATE CA ZIP <br />PHONE #1 EXT. <br />( ) <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 />2oZS93 CHECK if BILLING ADDRESS® <br />BUSINESS NAME <br />Service Station Testing -SST INC <br />COMMENTS: Replace 87 MLLD. <br />PHONE# ExT. <br />209 465-5577 <br />HOME or MAILING ADDRESS i <br />PO Box 31465 <br />FAX# <br />( 209 ) 465-4988 <br />CITY Stockton <br />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 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: C" I,— N� DATE: 5/10/12 <br />PROPERTY/ BUSINESS OWNER❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT <br />If APPL/CANT is not the BILLING PARTY, proof of authorization to sign is required <br />President <br />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 environmentaUsite 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: PIPING REPAIR <br />PAYMENT <br />COMMENTS: Replace 87 MLLD. <br />Correct diesel weep in STP sump. <br />MAY 17 2012 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />ACCEPTED BY: <br />EMPLOYEE #: <br />DATE: �7 . <br />DATE: !/ <br />ASSIGNED TO: <br />EMPLOYEE #: <br />Date Service Completed (if al <br />dy completed): <br />SERVICE CODE: <br />PIE: �f Q <br />Fee Amount: <br />LOWAmount <br />Paid <br />✓� / <br />Paymen <br />Date L:5 \-1 (f7 <br />Payment Type•. �L <br />Invoice # <br />Check # <br />Received By <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 1 111 7/2 00 3 <br />