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SAN JOAQUII. .:OUNTY ENVIRONMENTAL HEALTH __PARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE/REQUEST# <br /> GDF <br /> OWNER/OPERATOR Major Singh CHECK if BILLING ADDRESS❑ <br /> FACILITY NAME Delta Arco <br /> �V <br /> SITE ADDRESS 440 W Chart- Way , Stockton 95206 <br /> Street Number Direction V' 11 Street Name City Zio 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 ) 465-2487 l tv 5 v 3 o 0 3 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR Carl Wayne Henderson CHECK if BILLING ADDRESS <br /> BUSINESS NAME APEC PHONE# EXT. <br /> 209 943-3000 <br /> HOME or MAILING ADDRESS FAX# <br /> PO Box 55105 (209 ) 943-3003 <br /> CIN Stockton STATE CA ZIP 95205 <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 ENVIRONMI-N'rAL 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: C.w� ', - '�—� DATE: 2/25/11 <br /> PROPER"rY/BUSINESSOWNER❑ OPERA-FOR/N'IANAC[:R ❑ O-FIIERAt:1-11ORIZEDAGENT® <br /> ff APP/.K',I,V7 is no/the 1M,i./wc PARTY,proof of authorization to sign is required rule <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: U S TgYMENT <br /> COMMENTS: Replaced 208 sensor in#5/6 UDC on an emergency basis. R <br /> FEB 252011 <br /> SMI <br /> ENVIRONM SENT <br /> H1}I DEPAR <br /> ACCEPTED BY: EMPLOYEE#: 3 DATE: h II <br /> ASSIGNED TO: 5+a_c . 1 EMPLOYEE#: / DATE: O� <br /> Date Service Completed (if ready completed): 2/24/11 SERVICE CODE: P 1 E: O <br /> Fee Amount: Amount Paid 3 � L _ Payment Date Z f 2- <br /> Payment <br /> Payment Type �� Invoice# Check# ` 0 Received y: 1�� <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />