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SAN JOAQUIN�OUNTY ENVIRONMENTAL HEALTH JPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> GDF ?S / Spoc S g� y7 Cp <br /> OWNER/OPERATOR <br /> Jivtesh Gill CHECK if BILLING ADDRESS� <br /> FACILITY NAME 7-Eleven/76- Lodi <br /> SITEADDRESS 1111 E Kettleman Ln Lodi 95240 <br /> Street Number Direction I Str"t Name City Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Sheet Number Street Name <br /> CITY STATE CA ZIP <br /> PHONE#1 EXT' APN# LAND USE APPLICATION# <br /> ( 209 ) 369-3633 6y fra���O <br /> PHONE#2 EXT' BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR Carl Wayne Henderson CHECK If BILLING ADDRESS® <br /> BUSINESS NAME PHONE# EXT. <br /> HMC- Henderson Maintenance Company 209 467-7573 <br /> HOME or MAILING ADDRESS FAX# <br /> PO Box 31325 ( 209 ) 4654988 <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 /> also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN JoAQufN <br /> COUNTY Ordinance Codes,Standards,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: Com( t,_ ���— DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT® Contractor <br /> /fAPPL/CANT iS not the BILL/NG PARTY proof of authorization t0 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: TANK RETROFIT <br /> COMMENTS: ATG crash 10/5/09 required COLDSTART to recover. Printed ALARM HISTORY, COLDSTAR-Wftlity <br /> tested and placed site in service. RECEIVED <br /> Annual certification is due 12/2009. Will perform annual certification at permit approval. OCT 0 6 2009 <br /> Will r place U2 board and software prior to COLDSTARTANNUAL monitor certification. SANOAQUIINE OUN <br /> ACCEPTE Y: / EMPLOYEE M �T� DATE: <br /> ASSIGNED /— _� EMPLOYEEM DATE: <br /> Date Service Completed (if already completed): 10/5/09 SERVICE CODE: {�Z�� P 1 E:lzgodl:�' <br /> Fee Amount: 3Y OC7 Amount Paid 34 S Payment Date (O Ip (D <br /> Payment Type , Invoice# Check# �3 Received By: 2� <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />