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SAN JOAQUWOUNTY ENVIRONMENTAL HEALTHOPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />BUSINESS NAME <br />Service Station Testing -SST INC <br />SERVICE REQUEST # <br />GDF <br />� f 7 <br />/ <br />#7/8 boot replacement <br />209 465-5577 <br />HOME or MAILING ADDRESS <br />OWNER/ OPERATOR Douglas Smith <br />FAX# <br />CHECK if BILLING ADDRESSO <br />FACILITY NAME City of Stockton Corp Yard <br />( 209 ) 465-4988 <br />CITY Stockton <br />STATE CA ZIP 95213 <br />SITE ADDRESS 1465S <br />EMPLOYEE #: <br />Lincoln St <br />ASSIGNED TO: i I <br />Stockton <br />DATE: <br />95206 <br />Street Number <br />Direction <br />Street Name <br />Fee Amount: (� c'% <br />city <br />3 7 S 0 D <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Payment Type <br />Invoice # <br />Check #1171 Lf <br />Received By: <br />Street Number <br />Street Name <br />CITY <br />STATE CA ZIP <br />PHONE #1 EXT. <br />APN # <br />LAND USE APPLICATION # <br />( 209 1 937-7415 <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 />Service Station Testing -SST INC <br />COMMENTS: Secondary Containment repairs: <br />PHONE# EXT. <br />L <br />AUG 2 8 2012 <br />#7/8 boot replacement <br />209 465-5577 <br />HOME or MAILING ADDRESS <br />FAX# <br />PO Box 31465 <br />#5/6 electrical penetration repair. <br />( 209 ) 465-4988 <br />CITY Stockton <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 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 ,( ,� _ ,� �-- DATE: <br />PROPERTY/ BUSINESS OWNER 13 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. <br />TYPE OF SERVICE REQUESTED: <br />PA <br />COMMENTS: Secondary Containment repairs: <br />L <br />AUG 2 8 2012 <br />#7/8 boot replacement <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />#5/6 electrical penetration repair. <br />HEALTH DEPARTMENT <br />ACCEPTED BY: <br />EMPLOYEE #: <br />DATE: <br />ASSIGNED TO: i I <br />EMPLOYEE #: <br />DATE: <br />Date Service Completed (if already completed): <br />COC' <br />SERV7i�� <br />P I E: <br />Fee Amount: (� c'% <br />Amount Paid <br />3 7 S 0 D <br />nt Date <br />l L <br />Payment Type <br />Invoice # <br />Check #1171 Lf <br />Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />