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SAN JOAQUIN UNITY ENVIRONMENTAL HEALTH�PARTMENT <br /> 14 SERVICE REQUEST <br /> Type of Business or Property <br /> FACILITY ID# SERVICE REQUEST# <br /> - <br /> GDF 1 AN0C7 � Zy' � / <br /> OWNER/OPERATOR DP & DK Investments, Inc CHECK if BILLING ADDRESS❑ <br /> FACILITY NAME <br /> Shell <br /> SITE ADDRESS 1206 E March Lane Stockton 95210 <br /> Street Number Direction <br /> Street Name Cit Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) PAYMENT <br /> Street Number Street Name <br /> CITY <br /> STATE CA ZIP C <br /> PHONE#I EXT. APN# LAND USE APPLICATION# SAN JOAQUIN COU <br /> ( 209 ) 834-1220 V <br /> PHONE#2 EXT. BOS DISTRICT Efr <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR Carl Wayne Henderson q0 q 773 CHECK if BILLING ADDRESS® <br /> PHONE# EXT. <br /> BUSINESS NAME Service Station Testing -SST INC /CSLB 962520 ( 209 465-5577 <br /> FAx# <br /> HOME or MAILING ADDRESS PO Box 31465 ( 209 ) 465-4988 <br /> CITYStockton 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 /> 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: ( %.., DATE: 2/8/14 <br /> President <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT <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: <br /> COMMENTS: COLDSTART - Veeder-Root ATG. Power BLINK caused "UNRECOVERABLE DATA ERROR" <br /> ACCEPTED BY: <br /> EMPLOYEE#: -7 / 7L7 DATE: L`/ <br /> I+ �.��/? (� G <br /> ASSIGNED TO: <br /> 7-0 <br /> EMPLOYEE#: t�( ( _ DATE: <br /> � v v <br /> Date Service Completed (if already completed): 2/7/14 SERVICE CODE: 1 P/E Z 3 CJ <br /> Fee Amount: ,3 — Amount Paid 3 75',60 Payment Date i G <br /> Payment Type <br /> Invoice# Check# (y3 Received By:G <br /> SR FORM(Golden Rod) <br /> EHD 48-02-025 <br /> REVISED 11/17/2003 <br />