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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH bLeARTMENT WGINAL <br />SERVICE REQUEST <br />Type of Business or Property <br />CHECK If BILLING ADDRESS® <br />FACILITY ID # <br />-I JA7VCOMMENTS: 14 ?015 <br />SERVICE REQUEST # <br />GDF <br />FAX# <br />( 209 ) 465-4988 <br />CITY Stockton <br />STATE CA ZIP 95213 <br />OWNER/ OPERATOR <br />ACCEPTED BY: �- <br />EMPLOYEE #: <br />DATE: -� <br />' <br />CHECK If BILLING ADDRESS <br />FACILITY NAME ARCO <br />Date Service Completed if already Completed): <br />SERVICE CODE: <br />A <br />PIE: /► <br />SITE ADDRESS g00S <br />Amount Pal <br />Cherokee Ln <br />Payment Date s J/rj <br />Lodi <br />Invoice # <br />Check # I �S <br />95240 <br />Street Number <br />Direction <br />Street Name <br />City <br />Zio Code <br />HOME or MAILING ADDRESS (If Different from <br />Site Address) <br />Street Number <br />Street Name <br />CITY <br />STATE CA <br />ZIP <br />PHONE #1 EXT <br />209 570-4991 <br />APN # <br />���i -C)6� <br />LAND USE APPLICATION # <br />( ) <br />c <br />PHONE #2 EXT. <br />BOS DISTR IFT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR Carl Wayne Henderson 505324 <br />CHECK If BILLING ADDRESS® <br />BUSINESS NAME Service Station Testing - SST INC / CSLB 962520 <br />-I JA7VCOMMENTS: 14 ?015 <br />PHONE# EXT. <br />209 465-5577 <br />HOME or MAILING ADDRESS <br />PO Box 31465 <br />FAX# <br />( 209 ) 465-4988 <br />CITY Stockton <br />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 />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:( �` DATE: 1/13/15 <br />PROPERTY / BUSINESS OWNER❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT ® President <br />ff .-1 PPL/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 availablepwdaAthe same time it is <br />provided to me or my representative. ! In M>FAl, <br />TYPE OF SERVICE REQUESTED: <br />VF <br />87a & 91 STP sump sensor certification. <br />-I JA7VCOMMENTS: 14 ?015 <br />SqN jOgQUI <br />HE LTEIVHt pO A N MUNE <br />FNT <br />ACCEPTED BY: �- <br />EMPLOYEE #: <br />DATE: -� <br />ASSIGNED TO: <br />EMPLOYEE #: <br />DATE: <br />Date Service Completed if already Completed): <br />SERVICE CODE: <br />A <br />PIE: /► <br />Fee Amount:' <br />Amount Pal <br />(/ <br />_ ` <br />Payment Date s J/rj <br />Payment Type <br />Invoice # <br />Check # I �S <br />Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />