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SAN.TOA UIN C� <br /> Q OUNTY ENVIRONMENTAL HEALTHIOPARTMENT <br /> SERVICE REQUEST OpdGML <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> GDF <br /> OWNER/OPERATOR DP& DK Investments, Inc <br /> CHECK if BILLING ADDRESS <br /> FACILITY NAME Shell-Stockton <br /> SITE ADDRESS 1206 E March Ln Stockton 1�7210 <br /> Street Number Direction Street Name Ci Zi Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE CA ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> ( 209 ) 834-1220 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR It SERVICE REQUESTOR <br /> REQUESTOR Carl Wayne Henderson 405017 <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME Service Station Testing- SST INC/CSLB 962520 PHONE# EXT. <br /> 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 FEDERAL laws. <br /> APPLICANT'S SIGNATURE: �`f L— � DATE: 6/12/14 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT® President <br /> lf',4PPLICANT 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: MiCEIVE® <br /> COMMENTS: G <br /> Replaced 208 sensor at L-6(#9/10) UDC JUN 12 2014 <br /> SAN JOpQUIN COUNTY <br /> HEALTH 040ARTMOd <br /> / ACCEPTED BY: EMPLOYEE#: DATE: <br /> IGNED TO: &&&e EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): 6/11/14 SERVICE CODE: l L ,- P/E: 3�Q <br /> Fee Amount: - Amount Paid Payment Date l �� <br /> Payment Type Invoice# Check#/` 7 7 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />