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SAN JOAQu—, COUNTY ENVIRONMENTAL HEALTI ✓EPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> GDF (�C, �� <br /> OWNER/OPERATOR Jessie CHECK if BILLING ADDRESS <br /> FACILITY NAME ARCO- Manteca <br /> SITEADDRESS 1100S Main St Manteca 95337 <br /> Street Number Direction Street Name Cit 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 ) 825-6784 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR Carl Wayne Henderson <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> HMC - Henderson Maintenance Company 209 467-7573 <br /> t'r) <br /> HOME or MAILING ADDRESS FAX# 1 <br /> PO Box 31325 ( 209 ) 465-4988 <br /> CITY Stockton 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: L �_ /- fDATE; <br /> PROPERTI /BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT® Contractor <br /> ff APPLICANT is not the BILLING PART),proof of authorization to sign is required Tide <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: TANK RETROFIT <br /> t <br /> COMMENTS: Replace ECPU2 and software in existing TLS-350. Coldstart, operability test and certify P� t <br /> operability (observed). jp,EcE-N <br /> US <br /> Dz� -n <br /> SAEN0paN <br /> ACCEPTED BY: —EMPLo4EE#: DATE: <br /> ASSIGNED TO: ' EMPLOYEE#: DATE: !/ <br /> Date Service Completed (if already completed): SERVICE CODE: P 1 E: <br /> Fee Amount: 0v Amount Paid ��5�(JU Payment Date I D <br /> Payment Type ✓ Invoice# Check# l p l- ' Received By: � <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />