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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> tib 2/ <br /> OWNEiitIOPERATOR Kasam CHECKifBILLINGADDRESS® <br /> FACILITY NAME Manteca Valero <br /> SITE AU7RESS 1001 E YOSe ite <br /> Street Namber Direction Street Name cit Z Code <br /> HOME®'MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# !AND USE APPLICATION# <br /> ( ► (209)824-9282 <br /> PHONE R'2 t^r BOS DISTRICT LOCATION CODE <br /> ( �1 <br /> _ CONTRACTOR SERVICE REQUESTOR <br /> REQUIi:STOR Illm <br /> Carl W Henderson CHECK if BILLINGApgRgSS OU <br /> BUSINESS NAIVEPHONE# EXT. <br /> HMC-Henderson Maint Co (209)467-7573 <br /> HOME(�'r MAIUNr.ADDRESS Fax# <br /> PO Box 31325 - Stockton, CA 95213 <br /> (209 ► 465-4988 <br /> CITY STATE ZIP <br /> BILLENG 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 actil,ity will be billed to me or my business as identified on this form. <br /> 1 also certify that 1 have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUN'''Y Ordinance Coder,Standards,STA'rr.and FIiDF.RAI,laws. q <br /> APPLIICANT'S SIGNATURE: t` DATE:_!- <br /> PROPP113-V/BnSINENS OWNrR❑ OI'@RATOR/MANAGER ❑ OTHER AtrruonizrD AGENT® Cr6/'JT2A-cro <br /> I IfArrl,tc'ANT ie not the BILLING-PARTY,prof of authoriztttlmt to s gn is required Title <br /> AUTtfORIZATION 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 JOAQUW COUN rY ENVIRONMENTAL.I-II Ai,rl i DrTARrMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. _ PAYMENT <br /> TYPE 0i SERvicE REQUESTED: AALL.) RECEIVES) <br /> COMMEFiTS: <br /> Replaced-MLLD during Annual Monitor Certification with Muni onsite. ,SAN 6 ZQ�9 <br /> 99LD-2000 NEW SER#08121049 (Replaced like for like) SAN OUIN COUNTY <br /> ENAViRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEP i ED BY: EMPLOYEE#: DATE: <br /> AsstwIED TO: EMPLOYEE#: DATE: <br /> 141/4 4py <br /> Date d�ervice Completed (if already completed): 1/ X09 SERVICE CODE: / P I E. <br /> Fee Ariount: Amount Paid 3\e Payment ate D <br /> e <br /> Paymant Type , ,- Invoice# Check# Received By: r <br /> EHD 4£-02-025 SR FORM(Golden Rod) <br /> REVISED 11117/2003 <br />