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SAN JOAQUIN i OUNTY ENVIRONMENTAL HEALTH AARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OL Oy- h <br /> OWNER/OPERATOR Chacko Thomas CHECK If BILLING ADDRESS❑ <br /> FACILITY NAME Texaco- Emil's Liquor <br /> SITEADDRESS 1405 California St Escalon 95320 <br /> SVeet Number I Direction I Street Name cily zip COAe <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE CA ZIP <br /> PH0NE#1 Exr' APN# LAND USE APPLICATION# <br /> ( 209 ) 838-7674 <br /> PHONE#2 EXT. BOS DISTRICT LOCATON CODE <br /> (ClifDo <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR Carl Wayne Henderson 2,0Z,,r9(o CHECK if BILLING ADDRESS® <br /> PHONE# En. <br /> BUSINESS NAME Service Station Testing-SST INC 209 465-5577 <br /> HOME Or MAILING ADDRESS FAX# <br /> PO Box 31465 ( 209 1 465-4988 <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 FEDERAL laws. <br /> APPLICANT'S SIGNATURE: GA-4 L, H DATE: 5/3/12 <br /> PROPERTY/BUSINESS OWNER❑ 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. <br /> TYPE OF SERVICE REQUESTED: PIPINGREPAIR/RETROFIT PAyMEN <br /> COMMENTS: #3/4-diesel shear valve repair/replace as needed. Rvm ' <br /> ,ry1t % 2012MAY 0 7 2012 <br /> \"S�ORDU� Q�yTv <br /> ,I f MIT/SENMENTALHEALTH <br /> H�1r AR RMIT/SERVICES <br /> ACCEPTED BY: <br /> EMPLOYEE M DATE: <br /> ASSIGNED TO: EMPLOYEE M DATE: <br /> Date Service Completed (if already Completed): SERVICE CODE: P I E: (� <br /> Fee Amount: '� Amount Paid �'� �� Payment Date S 2 <br /> Payment Type �' Invoice# Check# 'no Received By: I,--( - <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />