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• SAN JOAQUWOUNTY ENVIRONMENTAL HEALTHOPPARTMENT ORIGINAL <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> GDF rAC003LI1'3� IiG7-C3L- <br /> OWNER/OPERATOR City of Stockton- Fleet Mgmt CHECK if BILLING ADDRESS <br /> FACILITY NAME CORP YARD <br /> SITE ADDRESS 1465S Lincoln St Stockton 95206 <br /> Street Number Direction Street Name C ity Zip 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 /> ( 209 ) 937-7415 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR Carl Wayne Henderson 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: C---� t—� �'�— DATE: 6/18/15 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT® President <br /> /f APPLICANT is not the BILLING PARTY,proof of authorization to sign is required 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. A <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: L-3(diesel annular sensor) High Liquid alarm. JO/V9 <br /> 303 sensor must be replaced. SACj y�gq�1 ?® <br /> NFq�Ty�O qR�q1, 'Y <br /> TMF <br /> ACCEPTED BY: (s�`(wjj�� tf EMPLOYEE#: DATE: (5 <br /> ASSIGNED TO: l� Y �� V ` EMPLOYEE#: DATE: <br /> Date Service Completed (if already Completed: SERVICE CODE: C� P 1 E: <br /> Fee Amount: 3rlf 6)0 1 Amount Pai 3170. D D Payment Date <br /> Payment Type Invoice# Check# Rece ved By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />