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SAN JOAQUIP- `-'OUNTY ENVIRONMENTAL HEALTY "" EPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />CHECK If BILLING ADDRESS® <br />FACILITY ID # <br />COMMENTS: <br />ERVICE REQUEST # <br />GDF <br />FAX # <br />( 209 ) 465-4988 <br />CITY Stockton <br />STATE CA ZIP 95213 <br />OWNER /OPERATOR <br />OCT 2 5 2013 <br />Manny <br />CHECK if BILLING ADDRESS❑ <br />FACILITY NAME Valley Arco <br />ACCEPTED BY: V/j ",� <br />Y l <br />EMPLOYEE #: 7 /" <br />vt7r <br />SITEADDRESS 16 <br />E TH;;ing <br />I <br />Way <br />Stockton <br />DATE: <br />95204 <br />Street Number <br />Direction <br />Street Name <br />city <br />Fee Amount: -4— <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Payment Date <br />to <br />Payment Type <br />Street Number <br />Street <br />Name <br />CITY <br />STATE CA <br />ZIP <br />PHONE #1 EXT. <br />APN # <br />LAND USE APPLICATION # <br />( 206 ) 466-9516 <br />_- o-uj — O I <br />PHONE #2 EXT. <br />BOS DISTRICT <br />11 <br />LOCATION CODE <br />( <br />00 <br />O ( <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 />COMMENTS: <br />PHONE# EXT. <br />209 465-5577 <br />HOME or MAILING ADDRESS <br />PO Box 31465 <br />FAX # <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: r, (_-_. DATE: 10/25/13 <br />PROPERTY/ BUSINESS OWNER❑ <br />OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT <br />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: I <br />COMMENTS: <br />MEN I <br />RECEIVED <br />H-8 ATG crash. Replaced battery, coldstarted <br />and restored. <br />OCT 2 5 2013 <br />SAN JOAQUIN COUNTY <br />ENVIHOMENTAL <br />ACCEPTED BY: V/j ",� <br />Y l <br />EMPLOYEE #: 7 /" <br />vt7r <br />DATE: 0 / 2 <br />J <br />ASSIGNED TO: k <br />�AiN'n <br />EMPLOYEE #: f' <br />DATE: <br />Date Service Com ted (if alread ompleted): 10/25/13 <br />SERVICE CODE: I <br />PIE:,7 d <br />Fee Amount: -4— <br />Amount Paid <br />3 S' <br />Payment Date <br />to <br />Payment Type <br />Invoice # <br />Check # 0��5-D9 <br />Received By <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />