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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> E <br /> roperty FACILITY ID# SERVICE REQUEST# <br /> GDF Il 11 64(11 �to4Sn3 <br /> CHECK if BILLING ADDRESS❑ <br /> rtherChevron <br /> 3400N MacArthef Tracy 95376 <br /> SVoet Number e C Do Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Streel Number treat Name <br /> CITY STATE CA ZIP <br /> PHONE#1 Eff' APN# LAND USE APPLICATION If <br /> (209 ) 834-1220 <br /> PHoNE#2 15V. BOS DISTRICT LOCAnON CODE <br /> 1 ) <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REOUESTOR Carl Wayne Henderson CHECK it BILLING ADDRESS® <br /> BUSINESS NAME PHONE# En. <br /> Service Station Testing-SST INC 209 465-5577 <br /> HOME or MAILING ADDRESS FAx# <br /> PO Box 31465 1209 ) 465-4988 <br /> CITY Stockton STATE CA Zip 95213 <br /> BILLING ACKNOWLEDGEMENT: 1, 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 /> 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 <br /> COUNTY Ordinance Codes,Standards,STATE and FEDEEPAL� 2 <br /> APPLICANT'S SIGNATURE: C.-.,( r-.-- N DATE:_3_ ✓ I 'f <br /> PROPERTY/BUSINEss OWNER 13 OPERATOR/MANAGER O 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 available and at the same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: Rrrrfvpn <br /> CoMNENrs: EMERGENCY Sensor replacement _ - <br /> MAR 0 5 2012 <br /> SMI nAQUN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: Lowe EMPLOYEE#: q&)S-o�, DATE: 3 c" 12, <br /> ASSIGNED TO: EMPLOYEE# IC <br /> : q / ( DATE: 3 J <br /> Date Service Completed (Ifalreadywmpleted): 3 2AL I <br /> SERVICE CCODE: r ff I PIE: 2�b <br /> Fee Amount: AmountPaid T375. civ Payment Date v <br /> Payment Type Invoice# Check# 116 Received By. a <br /> EHD 49-02.025 SR FORM(GokNm Rod) <br /> REVISED 11/172003 l <br />