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7 <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property GDF FACILITY!ID# nnSERVICE REQUEST# <br /> I n 0 D (( _ S I -O(;) i-- -7 13-0 <br /> OWNER/OPERATOR Vic Judge g CHECK if BILLING ADDRESS <br /> FACILITY NAME ABC Food Mart - Valero <br /> SITE ADDRESS 713 1 N EI Dorado St Stockton 95202 <br /> Street Number Direction I 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 /> ( 661 ) 706-3298 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR Carl Wayne Henderson 2%3 B40 <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> Service Station Testing-SST INC 209 465-5577 <br /> HOME or MAILING ADDRESS FAx# <br /> PO Box 31465 ( 209 ) 465-4988 <br /> CIN 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 /> 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: ��,/ �� DATE: 5/14/13 <br /> PROPERTY/BUSINESS OWNER 11 OPERATOR/MANAGER ❑ 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 s iie time it is <br /> provided to me or my representative. pq <br /> TYPE OF SERVICE REQUESTED: TANK RETROFIT C <br /> COMMENTS: PER ANNUAL Monitor Certification: Replace 87 fill bucket&test diesel PLLD Y 1 <br /> N SAI <br /> A/N�goctt c2�13 <br /> TH of 4 tot.h <br /> hT <br /> ACCEPTED BY: EMPLOYEE#: -7 () DATE: C/�(� /3 <br /> ASSIGNED TO: ;F EMPLOYEE#: DATE: J <br /> Date Service Completed (if already c leted): SERVICE CODE: t /�] PIE: 23 U <br /> Fee Amount: S S Amount Paid <br /> 37500 Payment Date 511! 3 <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 / SR FORM(Golden Rod) <br /> REVISED 11/17/2003 ( � I <br />