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SAN JOAQUI1 OUNTY ENVIRONMENTAL HEALTH MPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> GDF 1 Z.�-,? .S✓�6 �O�O���� <br /> OWNER/OPERATOR Parmeet Dhalawal t <br /> CHECK if BILLING ADDRESS <br /> FACILITY NAME 76 March Lane <br /> SITEADDRESS 1206E March Ln Stockton 95210 <br /> Street Number Direction Street Name City Zi o 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 /> ( ) <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR Carl Wayne Henderson 3c'3+7?CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> Service Station Testing - SST INC 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 /> 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 andFEDERAL laws. <br /> � <br /> APPLICANT'S SIGNATURE: C 1-11-e-1-- DATE: 1/29/13 <br /> PROPERTY/BUSINESS OWNER[I OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT® President <br /> IfAPPLICANT APPLICANT is not the BILLING PARTY,proof Of authorization to sigh 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: M <br /> COMMENTS: Install replacement DIM, coldstart ATG and restore from archive. Perform annual Monitor certifio <br /> placing site in service. S `oZic <br /> F�Oq O <br /> Different(new) DIM will not be recognized by ATG without coldstart. hF, /4- M NTUH� <br /> g9TM� <br /> ACCEPTED BY: w EMPLOYEE#: Q o c--f/ DATE:PW r/� // <br /> ASSIGNED TO: hw5 EMPLOYEE#: 3 DATE: 2 ( h s <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: <br /> Fee Amount: i Amount Paid 3`j,Q(� Payment Date ? I <br /> 1.3 <br /> Payment Type V Invoice# Check#laDy�7— Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />