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2 + <br /> SAN JOAQUIN COUNTY ENVIRONMEN &. > NT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY dir Ix JL ISERVICE REQUEST# <br /> GDFENVIRKIAA IVIVILM I <br /> OWNER/OPERATOR Il <br /> National Petroleum CHECK if BILLING ADDRESSO <br /> FACILITY NAME Mr Cafe <br /> SITE ADDRESS 713 IN EI Dorado St Stockton 95202 <br /> Street Number Direction Street Name Ci Zi 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 TbS3414 CHECK if BILLING ADDRESS® <br /> BUSINESS NAMEPHONE# Ems' <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 JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: Cā€” -f I-- DATE: 3/17/15 <br /> PROPERTY/BUSINESS OWNER 1:1 OPERATOR/MANAGER ā‘ OTHER AUTHORIZED AGENT® President <br /> If APPLICANT 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 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: <br /> COMMENTS: <br /> 91/diesel Annular Sensor replacement(L-10) <br /> 91 PLLD Transducer replacement(Q-2) <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): 3/16/15 SERVICE CODE: P/E: <br /> Fee Amount: Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 \ 0, it) <br />