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SAN JOAf P*OUNTY ENVIRONMENTAL HEALTH AARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />SERVICE REQUEST # <br />GDF <br />®��� <br />r �/%9 Z - <br />OWNER / OPERATOR <br />209 943-3000 <br />Bob Lutz <br />CHECK tfBILLING ADDRESSO <br />FACILITY NAME EI Dorado Food Mart <br />PO Box 55105 <br />SITE ADDRESS 2320 <br />IN <br />I EI Dorado St <br />STATE CA ZIP 95205 <br />Stockton <br />I <br />95209 <br />Street Number <br />Direction <br />Payment Date <br />Street Name <br />city <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Check # 1 1 <br />Received By: �r <br />Street Number <br />Street Name <br />CITY <br />STATE CA ZIP <br />PHONE #1 EXT. <br />APN # <br />LAND USE APPLICATION # <br />( 209 ► 943-1311 <br />PHONE #2 EXT. <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR Carl Wayne Henderson <br />CHECK If BILLING ADDRESS <br />BUSINESS NAME <br />APEC <br />COMMENTS: COLD START: <br />TLS -350 crashed 1/5/2011 at 8 p.m. Coldstart required to restore. JAN - 7 2011 <br />SAN 14 COUNT"' <br />NVIRONMENT L <br />HEATH DEPARTMENT <br />OP <br />PHONE # EXT. <br />EMPLOYEE #: q <br />r <br />209 943-3000 <br />HOME or MAILING ADDRESS <br />FAx# <br />PO Box 55105 <br />Date Service Completed (if already completed): 1/5/11 <br />( 209 ) 943-3003 <br />CITY Stockton <br />STATE CA ZIP 95205 <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 />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 FED RAL laws. <br />APPLICANT'S SIGNATURE: �y� ,` , ,� DATE: 1/6/11 <br />PROPERTY /BUSINESS OWNER OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT <br />/f APPL/CANT is not the BILLING PARTY, proof of authorization to sign is required <br />Technician <br />Title <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, 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 />PAYMENT <br />COMMENTS: COLD START: <br />TLS -350 crashed 1/5/2011 at 8 p.m. Coldstart required to restore. JAN - 7 2011 <br />SAN 14 COUNT"' <br />NVIRONMENT L <br />HEATH DEPARTMENT <br />OP <br />ACCEPTED BY: <br />EMPLOYEE #: q <br />r <br />DATE: <br />ASSIGNED TO: - <br />EMPLOYEE #: <br />DATE: <br />Date Service Completed (if already completed): 1/5/11 <br />SERVICE CODE: <br />PIE: <br />Fee Amount: 00 <br />Amount Paid <br />b L <br />Payment Date <br />7 I' <br />Payment Type I/ <br />Invoice # <br />Check # 1 1 <br />Received By: �r <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />