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t r <br /> SAN.JOAQUi<,r COUNTY ENVIRONMENTAL HEALTAPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property _ FACILITY ID# SERVICE REQUEST# <br /> GDF lLi�d60 377, ' <br /> OWNER/OPERATOR Van de Pol CHECK if BILLING ADDRESS <br /> FACILITY NAME Pacific Pride <br /> SITEADDRESS 351 N Beckman Lodi 95240 <br /> Street Number Direction I Street Name it Zi 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 /> I ► 0yyo30i <br /> PHONE#Z EXT. BOS DISTRICT7T71 LOCATIO CODE <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: 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. t.—. /1✓G DATE: 1/18/11 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER OTHER AUTHORIZEDAGENTM Technician <br /> If APPLICANT is not the BILLING PARTY,proof of,—,thorization 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: v✓� /d � PAYMENT <br /> COMMENTS: Sensor damaged during TANK RELINING operation. HECEIVED <br /> JAN 19 2011 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTE BY: EMPLOYEE#: DATE:��/S�j <br /> ASSIGNED TO: �J �� �� EMPLOYEE#: ��/aa DATE <br /> Date Service Completed (if already completed): / SERVICE CODE: 11,5V PIE: 08 <br /> Fee Amount: 342�.-a Amount Paid -t� 3L 1` Payment Date <br /> Payment Type ✓ Invoice# Check# 11003 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />