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SAN JOAQU*OUNTY ENVIRONMENTAL HEALTH WARTMENT LJ <br /> ORIGINAI, <br /> SERVICE REQUEST <br /> Type of Business or Property _ FACILITY ID# SERVICE <br /> REQUEST# <br /> GDF �` nno % �l.l' 7�C� �(✓ <br /> OWNER/OPERATOR Platinum Realty- Krishna Gajjala-(510)414-6443 CHECK if BILLING ADDRESS❑ <br /> FACILITY NAME Quick Stop Market <br /> SITE ADDRESS 2057 S EI Dorado Street Stockton 95206 <br /> Street NumberJ 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 /> ( 510 ) 414-6443 1 IV515�"R <br /> PHONE#2 ExT. BOS DISTRICT LOCATION CODE <br /> ( ► <br /> CC", C <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR Carl Wayne Henderson 505446 CHECK if BILLING ADDRESS® <br /> BUSINESS NAMEPHONE# ExT. <br /> Service Station Testing-SST INC/CSLB 962520 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 FE ERAL laws. <br /> 1 <br /> APPLICANT'S SIGNATURE: DATE: 4/24/15 <br /> PROPERTY/BUSINESS OWNER❑ 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, 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 awn�d�a 0same time it is <br /> provided to me or my representative. GY^M ��V <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: Repaired TLS-300C sensor/probe wires in electrical gutter. APRy <br /> N JOA�IVME O� <br /> SA EN*41R0 pAptM00 <br /> HEpL�H pE <br /> ACCEPTED BY: - EMPLOYEE#: DATE: f <br /> ASSIGNED TO: - ' EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): 4/23/15 SERVICE CODE: P I E:C-;l n � <br /> Fee Amount: , - �-( Amount Paid 'U 390 `O Payment Date mac{ S <br /> Payment Type ✓ Invoice# Check# ('Z03 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />