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-------------------------- ------------------------ --- - - --------- <br /> SAN JOAQUIN•LINTY ENVIRONMENTAL HEALTH ARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> GDF <br /> OWNER/OPERATOR DP & DK Investments, Inc CHECK if BILLING ADDRESS❑ <br /> FACILITY NAME Shell <br /> SITE ADDRESS 1206 E March Lane Stoc�City <br /> 95210 <br /> Street Number Direction <br /> Street Name 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#T EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR Carl Wayne Henderson q6 q 7 Z3 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 /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT <br /> 10 President <br /> IfAPPLICANT is not the BILLING PARTY,proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1,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: 7Check <br /> EE#: DATE: <br /> ASSIGNED T0: <br /> EE#: DATE: <br /> Date Service Completed (if already completed): 2/7/14 SERVICE CODE: P I E: <br /> Fee Amount: Amount Paid Payment Date <br /> Payment Type Invoice# Received By: <br /> SR FORM(Golden Rod) <br /> EHD 48-02-025 <br /> REVISED 11/17/2003 <br />