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SAN JOAQUIN r'OUNTY ENVIRONMENTAL HEALTI EPARTMENT <br /> R <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY I-D7# SERVICE REQUEST# <br /> GDF 3.2 ' 1K 0 7,5 Ob <br /> OWNER/OPERATOR Basmagi Angle CHECK if BILLING ADDRESS❑ <br /> FACILITY NAME 99 Shell <br /> SITE ADDRESS 7700 Moreland Ct Stockton CA <br /> Street Number I Direction Street Name city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE 95212 ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> ( 209 > 957-5398 <br /> PHONE#2 EXT• BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR Carl Wayne Henderson r-u r1 HECK if BILLING ADDRESS <br /> BUSINESS NAME (PHONE# EXT. <br /> Service Station Testing -SST INC/CSLB 962520 209 465-5577 <br /> HOME or MAILING ADDRESS FAX# <br /> PO Box 31465 (209 ) 465-4988 <br /> CITY Stockton 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 /> I also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUFN <br /> COUNTY Ordinance Codes,Standards,STATE and FEDERAk laws. <br /> APPLICANT'S SIGNATURE: DATE: 8/31/16 <br /> PROPERTY/BUSINESS OWNER[:] OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT In President <br /> IfAPPL/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 Apdf at the same time it is <br /> provided to me or my representative. PAY&]E <br /> TYPE OF SERVICE REQUESTED: ►VEp <br /> COMMENTS: 2016 <br /> Replace 304 sensor at L-12 (diesel fill annular brine) SAN�SEP OAQl1I <br /> FNVIROrWE CO11IVTy <br /> Diagnose& repair BRINE COMMUNICATION at#5/6 UDC annular "CAL-Ft, <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: I EMPLOYEE#: DATE: _ f_ <br /> ltp <br /> Date Service Completed (if already completed): SERVICE CODE: (;) P/E: 7- og <br /> Fee Amount: I �� Amount Pai [� v� Payment Date <br /> Payment Type Invoice# Check# '�e{g� Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />