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II� <br />:.SAN JOAQUCOi?NT1' LNVIRONMENTAL,H <br />EALT%IIPEPARTMENT <br />g U'. SERVICE REQUEST <br />Type of Business or Property <br />FACiL TY 16 # <br />SERVICE REQUEST #. <br />GDF <br />ExT' <br />209 465-5577 . <br />HOME or MAILING ADDRESS S <br />PO Box 31465 t <br />OWNER /,OPERATOR <br />Auburn 7-70 Inc + <br />FAX # <br />( 209) 465-4988 <br />CHECK "If BILLING ADDRESS <br />FACIUTYNAME- Arcij - Mop'dale' j <br />DATE: <br />Date Service Completed (if already completed): 11/27/1 <br />a <br />SERVICE CODE: <br />P 1 E: <br />SITE ADDRESq #44 . <br />Amount Pai <br />Mossdale Rd <br />i a ' . <br />Lathrop <br />Invoice #. <br />.95330 <br />*� Stnwt Number <br />Received By: <br />svw NAIiie <br />cftv <br />Zip C6de <br />HOME or MAILING ADDRESS (H Dftr"t ftm Site Address) ' <br />troet Number <br />clTY <br />STATE CA <br />ZIP <br />PHONE #j ExT' <br />APN # <br />3� 10 3 90 <br />LAND USE APPLICATION # <br />( 209 <br />PHONE R EXT. <br />( ) <br />BOS DISTRICTO <br />` <br />> <br />LOCATIIOON�DE <br />t <br />CONTRACTOR[ SERVICE REQUESTOR <br />AtOUESTOR q Carl Wayne Henderson. <br />CHECK If BILLING ADDRESS® <br />BUSINESS NAMEPHONE# <br />Service Station Testing -SST INC / CSLB 962520 <br />ACCEPTED BY: ' ;' <br />ExT' <br />209 465-5577 . <br />HOME or MAILING ADDRESS S <br />PO Box 31465 t <br />DATE: (L ? <br />FAX # <br />( 209) 465-4988 <br />CITY` ,$tOCktpn <br />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 s. <br />Specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated,.with this. <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 SAr Vpu <br />COL1NiY Ordinance Codes, Standards, STATE and FED'EPAL laws. 0 3 <br />` EN SqN JOA 2013 . <br />APPLICANT'S SIGNATURE:` L:.: /�� DATE: '11/27/13 ©0//y C <br />O , <br />PROPERTY/ BUSINESS OwNERO OPERATOR/ MANAGER D OTHER AUTHORIZED AGENT ® President �N Dpi NTq�MY <br />If APPLICANT is not the BILLING PARTY proof of authorization to sign is required Title MFM' <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 and at the same time it is <br />nrovided to me or my representative. <br />TYPE OF SERVICE REQUESTED: <br />COMMENTS:; Replaced damaged TLS -350 Power'Supply, A/C Input Module & Transforrr)er after POWER SPIKE damage. <br />P,&grammed and checked`operatrion. <br />ACCEPTED BY: ' ;' <br />EMPLOYEE M <br />DATE: (L ? <br />ASSIGNED TOC - yl -�� <br />EMPLOYEE M <br />DATE: <br />Date Service Completed (if already completed): 11/27/1 <br />a <br />SERVICE CODE: <br />P 1 E: <br />Fee Amount: 3:16'0171 <br />Amount Pai <br />3-75°OD <br />Payment Date > <br />.Payment Type <br />Invoice #. <br />Check # � � S� <br />Received By: <br />EMD 49-02-025 <br />REVISED 11/17/, OGS <br />SR FORM (Golden Rod) <br />