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SAN JOAQUI*LINTY ENviRoNMENTAL HEALTH OARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> GDF <br /> OWNER'/OPERATOR Mike Hamed EIVE® CHECK If BILLING ADDRESS❑ <br /> FACILITY NAME Kwik Sery <br /> Pr; <br /> SrtEADDRESS 824 E Yosemite Manteca 95336 <br /> Street Number 'AICf I C <br /> HOME Or MAILING ADDRESS (If Different from Site Address) meeHEAL ME.NT <br /> St Number SteNymp <br /> CITY STATE CA ZIP <br /> PHONE#1 ECa APN# LAND USE APPLICATION# <br /> ( 209 ) 823-8800 <br /> PHONE#2 ECT. BOS DISTRICT LOCATION CODE <br /> i ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR Carl Wayne Henderson CHECK If BILLING ADORESs® <br /> PHONE# ECT' <br /> BUSINESS NAME <br /> Service Station Testing -SST INC/CSLB 962520 0 77 <br /> HOME Or MAILING ADDRESS FAX# <br /> PO Box 31465 (209 ) 465-4988 <br /> CITY Stockton STATE CA 7aP 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: 1_.�J'� DATE: 10/18/13 <br /> PROPERTY/BUSINESS OWNER13 OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT® President <br /> IjAPFLJCANT 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 environmentaUsite 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: <br /> Colu ENTs: Coldstart after H-8 crash 10-17-2013 during 989 testing. <br /> Secondary containment repairs. <br /> ACCEPTED BY: EMPLOYEE DATE: <br /> ASSIGNED TO: EMPLOYEE M DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: <br /> Fee Amount: Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />