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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> CHECK if BILLING ADDRESS <br /> FACILITY NAME ARCO- Manteca <br /> SITEADDRESS 1100S Main Street Manteca 95337 <br /> Street Number Direction Street Name City Ziv 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 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 /> 1 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:Le_ /41� DATE 8/11/10 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT In Contractor <br /> ifAPPLICANT 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 UST R MFn <br /> COMMENTS: Replace TLS-350 ECPU board and software. Coldstart and Certify operability. ASG <br /> SgNJO 41. <br /> ENV AQU/N <br /> N IRO COr , <br /> FgCRy�E�77�F r�ry <br /> ACCEPTED By:-7` EMPLOYEE#: 0 DATE: 8 d <br /> ASSIGNED TO: IJIF <br /> EMPLOYEE#: ;�_, (, � DATE: Q <br /> Date Service Completed (if already completed): SERVICE CODE: 101 OP I E: 23v$ <br /> Fee Amount: Jl�j L+CG Amount Paid Payment Date $ 2-f(,_6 <br /> Payment Type Invoice# Check# l ✓l '� Received By: _ <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />