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' SAN JOAQU•OUNTY ENVIRONMENTAL HEALTHOPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> GDF <br /> OWNER/OPERATOR Sam Abundis CHECK If BILLING ADDRESS <br /> FACILITY NAME System Transport, INC <br /> SITEADDRESS 707 E Roth Rd French Camp 95213 <br /> Street Number Direction Street Name city Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Stre¢t Number Street Name <br /> CITY STATE CA ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (209 ) 83-8062 <br /> PHONE#2 ExT. BOS DISTRICT LOCATION CODE <br /> I ) I i <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUES OR Carl Wayne Henderson �C I �Z CHECK If BILLING ADDRESS® <br /> PHONE# ExT. <br /> BUSINES NAME <br /> APEC 209 943-3000 <br /> HOME Or MAILING ADDRESS FAX# <br /> PO Box 55105 (209 ) 943-3003 <br /> CITY Stockton STATE CA ZIP 95205 <br /> BILLIN S 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 activil y will be billed to me or my business as identified on this form. <br /> 1 also ce tify 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 /> APPLI ANT'S SIGNATURE: cl— P -H� DATE:5/25/11 <br /> PROPER /BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT® Techninian <br /> If APPLICANT is not the BILL/NO PARTY proof of authorization to sign is required Title <br /> AUTH RIZATION 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 /> informat on 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: Replace UDC sensor(L-4) due to damaged cable. Per UST Inspection Report dated 5/24/2011. PAYME1 IT <br /> RECEIV D <br /> MAY 2 6 o» <br /> SAN JOAQUINOUNTY <br /> LN^ �r ENVIRONM TTAENT <br /> ACCEPTED BY: I--d we EMPLOYEE#: 9D6 T[ DATE: <br /> ASSIGNED TO: EMPLOYEE#: 2 (��uG DATE: <br /> Date Se ice Completed (if already completed): SERVICE CODE: t 9d PIE: 2 -30 <br /> Fee Amount: 3&6,049 Amount Paid L 11_0-0 Payment Date Zb <br /> Payment Type Invoice# Check# Z Received By:-Z�/-- <br /> EHD 48- 2-025 SR FORM(Golden Rod) <br /> REVISE 11/17/2003 <br />