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SAN JOAQUI BOUNTY ENVIRONMENTAL HEALTI ?PARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property AND # r fSERVICE REQUEST# <br /> GDF <br /> L <br /> AND l V 5�0�� <br /> OWNER/OPERATOR Eugenia Valdez <br /> g CHECK if BILLING ADDRESS <br /> FACILITY NAME J&L Market <br /> SITEADDRESS 8115S EI Dorado St French Camp 95231 <br /> Street Number Direction I Street Name city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE CA ZIP <br /> # LAND USE APPLICATION# <br /> ( 209 ) 982-0897 PHONE#1 EXT. APN <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR Carl Wayne Henderson 605910 <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> Service Station Testing - SST INC/CSLB 962520 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 /> I also certify that 1 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 FED RAL laws. <br /> APPLICANT'S SIGNATURE: ,�� /�"_' DATE: 5/25/16 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT® President <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 40 it is <br /> provided to me or my representative. `"1Y <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: qN J 6' ~® <br /> Replaced 420 sensor at(L-5) 91/diesel tank annular(old sensor alarming, broken &expandeF Fiy'4Q 16 <br /> NOTE: Annual Monitor Certification is scheduled for 5-26-2016 ACTy1) 4FN�A h <br /> ATMA �Y <br /> T <br /> ACCEPTED BY: �nAOCI <br /> M A k EMPLOYEE#: DATE: - 1'Cj <br /> ASSIGNED TO: (�1 Lm tom" I+V � EMPLOYEE M DATE: J <br /> Date Service Completed (if already completed): 5/25/16 SERVICE CODE: G. P 1 E: a?� <br /> Fee Amount: C Amount P • 3?0 D2) Payment Date !� <br /> Payment Type Invoice# Check# �cReceiv d By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />