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SAN JOAQUIN UNTY ENVIRONMENTAL HEALTH DEPARTMEN ORIGIN <br /> SERVICE REQUESTL) AL <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> GDF RN U_o c-3 SRb 0 0_390 <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME Arco- Harding Way <br /> SITE ADDRESS 16 E Harding Way Stockton 95204 <br /> Street Number I Direction I Street Name city Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street NumberT Street Name <br /> CITY STATE CA ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> ( 209 ) 466-9516 ?J� �� — O f <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR Carl Wayne Henderson CHECK if BILLING ADDRESS® <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: 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 FEDE L laws. <br /> APPLICANT'S SIGNATURE: C_' .a 1^^• t� DATE: 8/25/14 <br /> PROPERTY/BUsiNESs OWNER[3 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 available and at the same time it is <br /> provided to me or my representative. 1' (� <br /> TYPE OF SERVICE REQUESTED: U 5 ) ATL I% PAYmPNT <br /> COMMENTS: COLDSTART TLS-350 & restore from archive after Crash. RECEIVEn <br /> Alarm history lost. AUG 2 6 2014 <br /> SAN JOAQUIN COUNTY <br /> ENV'ROMEHEALTH DI*ARTMENT <br /> ACCEPTEDBY: , aEMPLOYEE#: DATE: �' ( U <br /> ASSIGNED TO: ti J OYl EMPLOYEE#: DATE: <br /> Date Service Completed (if alreidly completed): 8/24/14 SERVICE CODE: f 5 PIE: <br /> Fee Amount: 0 Amount Paid Payment Date gp f <br /> Payment Type Invoice# ( Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Ro ) <br /> REVISED 11/17/2003 <br />