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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH%ARTMENT <br /> Q ORIGINAL <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY IDv# SERVICE REQUEST# <br /> GDF �Ll (c'� c) 4W0 7/ '755— <br /> OWNER/OPERATOR National Petroleum CHECK if BILLING ADDRESS❑ <br /> FACILITYNAME Mr Cafe <br /> SITE ADDRESS 713N EI Dorado St Stockton 95202 <br /> Street Number 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 ) 465-2887 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR Carl Wayne Henderson o57653t)1e CHECK if BILLING ADDRESS® <br /> BUSINESS NAMEPHONE# 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: 1, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific ENVIRONMENTAL HEALTI-T 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: L-- /�� DATE: 3/17115 <br /> PROPERTY/Bust NESS OWN ER El OPERATOR/MANAGER ❑ OTHERAUTHORIZE.DAGENT® President <br /> /f,4PPL1(-AN7'is not the BILLING PARTY,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 to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEAL'T'H DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. ni�e'r G <br /> TYPE OF SERVICE REQUESTED: t;�S / eFI <br /> COMMENTS: <br /> 91/diesel Annular Sensor replacement(L-10) <br /> 91 PLLD Transducer replacement(Q-2) M oA� <br /> S vo a <br /> ACCEPTED BY: �c— EMPLOYEE#: DATE: f tS"vN�f <br /> �M <br /> ASSIGNED TO: (Jf^,cJG EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): 3/16/15 SERVICE CODE: C P 1 E:�`3C,8 <br /> Fee Amount: ?�p. Amount Paid Payment Date 3 11 15 O <br /> Payment Type , Invoice# Check#©�aC7�� Received By. <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />