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SAN JOAQUI'♦C:OUNTY ENVIRONMENTAL HEALTAPARTMENT ORIGINAL <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# S��T# <br /> GDF �(� �� <br /> OWNER/OPERATOR City Of Stockton- Fleet Mgmt CHECK if BILLING ADDRESS❑ <br /> FACILITYNAME CORP YARD <br /> SITEADDRESS 1465S Lincoln St Stockton 95206 <br /> Street Number Direction Street Name city 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 /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR Carl Wayne Henderson 565ggS- CHECK if BILLING ADDRESS® <br /> BUSINESS NAME PHONE# Ems' <br /> Service Station Testing-SST INC/CSLB 962520 209 465-5577 <br /> HOME or MAILING ADDRESS FAX# <br /> PO Box 31465 ( 209 1 465-4988 <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: l ',e 1. /- DATE: 4/22/15 <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 ayaulable and at the same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: l5vC }. <br /> Colace 87 fill and vapor buckets due to fill bucket lake test failure. APR 2 3 2015 <br /> RECENE <br /> APR 2 3 2015 <br /> ENVIRONMENTAL HS <br /> rH <br /> s- OTMRSERVICWRNML <br /> ACCEPTED BY: \a(i oc�I EMPLOYEE#: DATE: <br /> ASSIGNED TO: e EMPLOYEE#: DATE: q <br /> Date Service Completed (If already completed): SERVICE CODE: MIS P/E: �2 -� <br /> Fee Amount: C ``)CC) Amount Pai 3q6.Z�D Payment Date <br /> Payment Type Invoice# Check# �av?J Rece ved By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />