Laserfiche WebLink
SAN JOAQUI�COUNTY ENVIROMENTAL HEALTH PEPARTMENT • <br />SERVICE REQUEST <br />Type of Business or Property <br />Carl Wayne Henderson <br />FACILITY ID # <br />BUSINESS NAME <br />HMC -Henderson Maintenance Company <br />SERVICE REQUEST # <br />GDF <br />EMPLOYEE #: L/./_ Z b <br />% cF cF -1 <br />10 <br />Date Service Completed (if already completed): 3/13/09 <br />209 467-7573 <br />4CE6X769 <br />OWNER/ OPERATOR <br />Fee Amount: 3 ,� <br />FAX # <br />Payment Date <br />Bob Lutz <br />Payment Type � <br />( 209 1 465-4988 <br />CHECK If BILLING AD ADDRESS <br />FACILITY NAME Shell - EI Dorado Food Mart <br />STATE CA Zip 95213 <br />SITE ADDRESS 2320 <br />N <br />EI Dorado <br />I <br />Stockton <br />95209 <br />Street Number <br />Direction <br />Street <br />Name <br />C ity <br />Zip Code <br />HOME or MAILING ADDRESS (if Different from Site Address) <br />Street Number <br />Street Name <br />CITY <br />STATE <br />ZIP <br />PHONE #1 EXT. <br />APN # <br />LAND USE APPLICATION # <br />( 209 ) 943-1311 <br />J Z�— <br />2-I0-30 <br />PHONE #2 EXT. <br />( ) <br />BOS DISTRICTCATION <br />IF <br />CODE <br />I <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />Carl Wayne Henderson <br />CHECK if BILLING ADDRESS <br />BUSINESS NAME <br />HMC -Henderson Maintenance Company <br />DATE: 1C.G <br />PHONE # EXT. <br />EMPLOYEE #: L/./_ Z b <br />DATE: <br />311&(02 <br />Date Service Completed (if already completed): 3/13/09 <br />209 467-7573 <br />HOME or MAILING ADDRESS <br />P / E: D-30 R <br />Fee Amount: 3 ,� <br />FAX # <br />Payment Date <br />PO Box 31325 <br />Payment Type � <br />( 209 1 465-4988 <br />CITY Stockton <br />Received By: <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 ENVIRONMENTAF. 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, STA IF, and FEDERAL, laws. <br />' PAYMENT <br />APPLICANT'S SIGNATURE: C t-- : /��✓�' DATE: 3/13/09 RECEIVED <br />PROPERTY/BUSINESS OWNER [3 OPERATOR/MANAGER ❑ OTHER AUTIIOR:ZEDAGENT 10 Contractor ���(� 1 6 2009 <br />1f.1 PPLICANT is not the Bii.LING PARTY, proof of authorization to sign is required Title <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, the owner or operator of the property Icgpt@dQAgpFN COUNTY. <br />NMENTAL <br />above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site a01me <br />PART E:NT <br />information to the SAN JOAQUIN COUNIY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the saA %it <br />Is <br />provided to me or my representative. GX"t 4'�4 IE <br />rT— <br />TYPE OF SERVICE REQUESTED: COLDSTART <br />COMMENTS: ATG lost programming during power outage and subsequent power spike. Printed ALARM HISTORY and <br />placed in ATG. Coldstarted ATG, restored setup and confirmed sensor operability. <br />ACCEPTED BY:LA v r t,. <br />Gv <br />EMPLOYEE #: O <br />DATE: 1C.G <br />_ . ! <br />ASSIGNED TO: I✓ t4 tr <br />EMPLOYEE #: L/./_ Z b <br />DATE: <br />311&(02 <br />Date Service Completed (if already completed): 3/13/09 <br />SERVICE CODE: %Ct Sr <br />P / E: D-30 R <br />Fee Amount: 3 ,� <br />Amount Paid 3) (� <br />Payment Date <br />3 b <br />Payment Type � <br />invoice # <br />Check # q q a-( <br />Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />