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SAN JOAQUAOUNTY ENVIRONMENTAL HEALTROPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> GDF %��Z 3�1Z�/ <br /> ��0U'10`fS 2. <br /> OWNER/OPERATOR <br /> City of Stockton CHECK If BILLING ADDRESS❑ <br /> FACILITY NAME City of Stockton Corp Yard ly6n P%M� <br /> SITE ADDRESS 1465 S Lincoln St 95206 <br /> streetVk <br /> Number Direction Street Name % Ci Zio Code <br /> HOME or MAILING ADDRESS (if Different from Site Address) 0 <br /> Street Number "AVJ// ame <br /> CITY ] ZIP <br /> tr <br /> PHONE#1 ExT. APN# LAND <br /> ( 209 ) 937-7415 b p <br /> PHONE#2 Exr. BOS DISTRICT LOCATION CODE <br /> ( ) 0° ( bf <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR Carl Wayne Henderson <br /> CHECK if BILLING ADDRESS <br /> BUSINESS NAME Service Station Testing-SST INC/CSLB 962520 PHONE# ExT. <br /> 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 FEDERAL laws. <br /> APPLICANT'S SIGNATURE: �F„✓P ✓ , DATE: 9/3/14 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT® President <br /> If 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. P <br /> TYPE OF SERVICE REQUESTED: �j{ �YD lrL RECEDE <br /> COMMENTS: COLDSTART TLS-350&restore from archive after crash. SEP 0 4 <br /> Alarm history lost. SAN JOAQUIN COUNTY <br /> ENVIROMENTAL <br /> HEATH DEPARTMENT <br /> ACCEPTED BY: - �,(�(Qjt„ EMPLOYEE#: DATE: / l- <br /> ASSIGNED TO: EMPLOYEE#: DATE: '1 <br /> Date Service Completed (if already completed): 9/3/14 1 <br /> SERVICE CODE: PIE: 23 0 9 <br /> Fee Amount: 2f y 0 Amount Paid act 0 Payment Date q I'-1 <br /> Payment Type ✓ Invoice# Check# 1 8 3q Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> ogt, <br /> REVISED 11/17/2003 l , <br /> t``_'''7-11 I <br />