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" e <br /> SAN JOAQU OUNTY ENVIRONMENTAL HEALTH PARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> GDF eve(p/S—A <br /> OWNER/OPERATOR CHECK if BILLING ADDRESS O <br /> FACILITY NAME Quick Stop Market <br /> SITE ADDRESS 2057S EI Dorado St Stockton 95206 <br /> Street Number Direction Street Name city i 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 ) 463-6474 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR Carl Wayne Henderson CHECK if BILLING ADDRESS® <br /> BUSINESS NAME PHONE# EXT. <br /> APEC 209 943-3000 <br /> HOME or MAILING ADDRESS FAX# <br /> PO Box 55105 (209 ) 943-3003 <br /> CITY Stockton STATE CA ZIP 95205 <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 /> 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 FEDERAL I S. <br /> APPLICANT'S SIGNATURE: ,�._ _ /� DATE: 11/23/10 <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT® Authorized Agent <br /> ff APPLICANT 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: TANK RETROFIT <br /> COMMENTS: 91 MLLD failed during annual monitor certification 11/22/2010. RECEIVED <br /> NOV 2 3 2010 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED EMPLOYEE#: p F DATE: it 12-3/(a <br /> ASSIGNED TO: EidPLOYEE#: l 4 Z DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: q P i E: Q� <br /> Fee Amount: d 0 Amount Paid 3(e p Payment Date [1)-2-30 <br /> Payment <br /> 1 -j- <br /> Payment Type Invoice# Check# 101.2-11 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />