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t SAN JOAQU0OUNTY ENVIRGNFOENTAL HEALTH OARTMENT �) SERVICE REQUEST Type of Business or Property CHECK If BILLING ADDRESS® FACILITY ID # SERVICE REQUEST # GDF 3 25 20� �.� 70 OWNER/ OPERATOR City of Stockton / Teri Williams CHECK if BILLING ADDRESS FACILITY NAME Municipal Service Center (Corp Yard) ASSIGNED TO: ( 209) 943-3003 SITE ADDRESS 1465S STATE CA Zip 95205 Lincoln St I e6plete(if already completed): Stockton SERVICE CODE: 95206 Street Number Direction Street Name City Payment Date Zip Code HOME or MAILING ADDRESS (If Different from Site Address) Invoice # Check #s Received By: Street Number Street Name CITY STATE CA ZIP PHONE #1 EXT. APN # LAND USE APPLICATION # ((209)) PHONE #2 EXT. BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR Carl Wayne Henderson CHECK If BILLING ADDRESS® BUSINESS NAME APEC COMMENTS: Replace existing AutoStik ATG with Veeder-Root TLS -350. Including Probes and Sensors as Q LVED PHONE# EXT. 209 943-3000 HOME or MAILING ADDRESS FAX # PO Box 55105 ASSIGNED TO: ( 209) 943-3003 CITY Stockton STATE CA Zip 95205 BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as identified on this form. 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 COUNTY Ordinance Codes, Standards, STATE and FEDERAL laws. APPLICANT'S SIGNATURE: /1�! DATE: ,`-- C(— C- &1' PROPERTY / BUSINESS OWNER❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT ® Technician /f APPLICANT is not the BILLING PARTY, proof of authorization to sign is required Title AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, the owner or operator of the property located at the above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. TYPE OF SERVICE REQUESTED: COMMENTS: Replace existing AutoStik ATG with Veeder-Root TLS -350. Including Probes and Sensors as Q LVED a MAy _ 9 20» SPJ� JOA ONp11E� E ENS pEPPRTM ACCEPTED BY: EMPLOYEE #: DATE: ASSIGNED TO: �` Y EMPLOYEE #: 2— DATE: Date Service e6plete(if already completed): SERVICE CODE: P 1 E: V Fee Amount: Amount Paid 13b Payment Date Payment Type Invoice # Check #s Received By: EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003