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SAN JOAQUIN"COUNTY ENVIRONMENTAL HEALTHEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />if BILLING ADDRESS <br />FACILITY ID # <br />'t 2 -W -k' <br />CHECK <br />SERVICE REQUEST # <br />'Sko© 5 5 -Zo 3 <br />OWNER / OPERATOR <br />PHONE# EXT. <br />(209) 467-7573 <br />CHECK if BILLING ADDRESS <br />FACILITY NAME 76 - Stockton Gateway <br />FAx # <br />SITE ADDRESS 322 S Centr <br />Street Number <br />St. Sto <br />Direction <br />ton Ca. 95203 <br />Street Name <br />STATE ZIP <br />citv <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Street Number <br />Payment Type <br />Street Name <br />CITY <br />STATE ZIP <br />PHONE #1 EXT. <br />1 ) 209-946-459 <br />APN #LAND <br />2 <br />t _ ( t <br />USE APPLICATION # <br />PHONE #2 EXT. <br />BOS DISTRICT <br />LOCA ION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />if BILLING ADDRESS <br />Carl W Henderson <br />CHECK <br />BUSINESS NAME <br />HMC -Henderson Maint Co <br />EMPLOYEE #: C 7- <br />PHONE# EXT. <br />(209) 467-7573 <br />HOME or MAILING ADDRESS PO Box 31325 - Stockton, CA 95213 <br />ASSIGNED TO: L�L�� LLt_ <br />FAx # <br />DATE: -> <br />( 209 ) 465-4988 <br />CITY <br />STATE ZIP <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 DEPARI'MENT 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, <br />,SSTATE <br />,sand FEDERAL laws. <br />APPLICANT'S SIGNATURE: (. ` --- DATE: ! / —Z2 <br />PROPERTY/BUSINESS OWNER❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZEDAGENTV <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. PAY Nji F NT <br />TYPE OF SERVICE REQUESTED:QST�Q tT <br />RECEIVED <br />COMMENTS: Replaced LLD 08-21-08, and operability tested. <br />AUG 2 2 2008 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />ACCEPTED BY: I�-J `A <br />EMPLOYEE #: C 7- <br />DATE: 2 Z % 6 Q <br />ASSIGNED TO: L�L�� LLt_ <br />?3 <br />EMPLOYEE #: .) J <br />DATE: -> <br />Date Service Completed (if already completed): S r`' _ �� <br />SERVICE CODE: <br />j � r <br />P 1 E: p <br />Fee Amount: tis' � <br />Amount Paid 1$ 3 S <br />Payment Date D <br />Payment Type <br />Invoice # <br />Check # qLfRec <br />ived By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />