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SAN JOAQUIiv COUNTY ENVIRONMENTAL HEALTINEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> F/4- 066 313 <br /> OWNER/OPERATOR <br /> B. S. Angle CHECK if BILLING ADDRESS <br /> FACILITY NAME Shell - Stockton <br /> SITE ADDRESS 7700 Moreland Ct Stockton 95212 <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 CA ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> ( 209 1 957-5398 <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 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,.Standardv,STATE and FEDE AL <br /> APPLICANT'S SIGNATURE: ,/ w DATE: 8/10/10 <br /> PROPERTY//BtSI NESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT® Contractor <br /> 1f.=1PPLICANT is not the BILLING PAL?_LT',proof of authorization to sign is required Title <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 t0 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 osr RECEIVED <br /> COMMENTS: Replace s-5 float switch found defective during annual monitor certification on 8/10/2010. AUG 1 1 201 <br /> SAN JOAQUIN COU TY <br /> ENVIRONMENTA <br /> HEALTH DEpARTME NT <br /> ACCEPTED BY: EMPLOYEE#: (,- DATE: a <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: i P I E: � CS <br /> Fee Amount: Amount Paid - 3�(o, 0-ic) Payment Date O <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />