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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH P�; PARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />BUSINESS NAME Service Station Testing - SST INC / CSLB 962520 <br />SERVICE REQUEST # <br />GDF <br />115 <br />Replaced Battery, restored from archive and checked operation. NOV 13 <br />6/uw &Y 4 &3 <br />OWNER/ OPERATOR <br />CHECK If BILLING ADDRESS❑ <br />FACILITY NAME Fast Lane <br />STATE CA ZIP 95213 <br />DATE: <br />SITE ADDRESS 116 <br />E <br />I <br />Lathrop Rd <br />Date Service Completed (if already completed): 11/12/13 <br />Lathrop <br />95330 <br />Street Number <br />Dlrectiom. <br />Payment Date f ( 3l ( <br />Street Name <br />Invoice # <br />Cit <br />Zi Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Street Number <br />Street Name <br />CITY <br />STATE CA ZIP <br />PHONE #1 ExT. <br />APN ¢# <br />LAND USE APPLICATION # <br />( 209 ) 234-4341 <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 Service Station Testing - SST INC / CSLB 962520 <br />PHONE # EXT. <br />( 209 465-5577 <br />HOME or MAILING ADDRESS <br />Replaced Battery, restored from archive and checked operation. NOV 13 <br />FAX # <br />PO Box 31465 <br />( 209 ) 465-4988 <br />CITY Stockton <br />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: �z t / DATE: 11/13/13 <br />PROPERTY / BUSINESS OWNER OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT ® President <br />IfAPPLICANT 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 />vM-1 to ma nr my renresentative. <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />PA <br />TYPE OF SERVICE REQUESTED:S�alarm <br />io:mmead <br />COMMENTS: ATG COLDSTART (GASOLINE SIDE): H-8 <br />Battery) <br />Replaced Battery, restored from archive and checked operation. NOV 13 <br />SAN JOA f tV <br />ENVIH() <br />HEALTF# €3EPART � <br />ACCEPTED BY: <br />EMPLOYEE #: 73 <br />DATE: <br />ASSIGNED TO: /�A <br />EMPLOYEE #: I (, q f, <br />DATE: <br />Date Service Completed (if already completed): 11/12/13 <br />SERVICES CODE:/1f S <br />P / E: -2- 30E' <br />Fee Amount: yl,�100 <br />Amount Paid ;,k _ <br />Payment Date f ( 3l ( <br />Payment Type <br />Invoice # <br />Check # I S 3 <br />Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />