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SAN JOAQU-, COUNTY ENVIRONMENTAL HEALTH ,EPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# _ <br /> GDF 000 y 03 <br /> OWNER/OPERATOR Jessie CHECK if BILLING ADDRESS <br /> FACILITY NAME ARCO- Manteca <br /> SITEADDRESS 1100 S Main St Manteca 95337 <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 /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> ( 209 ) 825-6784 <br /> PHONE#2 EXT. BOS DISTRICTLOCATION 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 ) 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: C,, �_ �1 DATE: f`1 <br /> PROPERTY/BUSINESS OWN ER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT® Contractor <br /> if APPL/CANT 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 time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: TANK RETROFIT <br /> COMMENTS: Replace ECPU2 and software in existing TLS-350. Coldstart, operability test and certify PACEyv <br /> operability (observed). RE Q9 <br /> Drco <br /> E� 1 pUt 1S'i <br /> SAEN�1Rp�P �-O,AENT <br /> ACCEPTED BY: E#: DATE: I <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> AA 7A�7 <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: T <br /> Fee Amount: O Amount Paid 1311+S o D Payment Date I D V <br /> Payment Type Invoice# Check# 19'f45- Received By: — <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />