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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT ORIGINAL <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> GDF :: W 0 14'M c ut zq q <br /> OWNER/OPERATOR Tracy Petro, INC CHECK If BILLING ADDRESS 1-3 <br /> FACILITY NAME Karam Singh <br /> SITEADDRESS 3400 N MacArthVr Dr Tracy 95376 <br /> Street Number Direction Street Name City I Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CRY STATE CA ZIP <br /> PHONE#1 E> . APN# LAND USE APPLICATION# <br /> ( 209 ) 834-1220 Z _ p - <br /> LOCATION CODE <br /> PHONE#2 EXT. BOS DISTRICT <br /> ( 1 0© ✓u <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR Cad Wayne Henderson yds 216 CHECK If BILLINGADDRESS® <br /> BUSINESS NAME PHONE# EXT. <br /> Service Station Testing-SST INC/CSLB 962520 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: 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 /> I also certify that 1 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 /> (o <br /> APPLICANT'S SIGNATURE: ri/ L--. �- DATE: 11/6/14 <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT® President <br /> 1f 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: r^ <br /> COMMENTS: Printed CURRENT alarm history &setup. v IVUV O 0 <br /> COLDSTARTED ATG to correct ISD Hose Mapping issue. SA J04 ' ?�14 <br /> EiyyOy <br /> Confirmed liquid sensor operability. HATH p0 gUgEINry <br /> E <br /> ACCEPTED BY: l / ' EMPLOYEE#: DATE: <br /> ASSIGNED TO: t vA/tl — EMPLOYEE M DATE: 1% <br /> Date Service Completed (if already mpleted): 11/6/14 SERVICE CODE: PIE: Q <br /> Fee Amount: �QiV �- Amount Pai 3q5e)Z) Payment Date 7 <br /> Payment Type Invoice# /, TCheck# ((('��'� �ei Z Race ved By: <br /> EHD 48-02-025 ,T`S,0 vv '7l ictSR FORM(Golden Rod) <br /> REVISED 11117/2003 U <br />