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ti <br /> SAN JOAQU*OUNTY ENVIRONMENTAL HEALTHOPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> ab 2/ <br /> OWNER/OPERATOR <br /> Kasam CHECK if BILLING ADDRESS <br /> FACILITY NAME Manteca Valero <br /> SITE ADDRESS 1001 E Yosite <br /> Street Numbert Direction I Street Name C ity Zi Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> 1 ) (209) 824-9282 <br /> PHONE#2 EXT. SOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> Carl W Henderson CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# ExT. <br /> HMC - Henderson Maint Co (209)467-7573 <br /> HOME or MAILING ADDRESS FAX# <br /> PO Box 31325 - Stockton, CA 95213 <br /> 1 209 1 465-4988 <br /> CITY STATE ZIP <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 FIFAI.TH Dr-',PARTMENT 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 /> COUN IY Ordinance('Odes,Standards,S IA IL:and FI:DFRAI, laws. <br /> APPLICANT'S SIGNATURE: �� I `. � _�_ DATE: <br /> PROPERTY/fit SINESSOWNER❑ OPERATOR/MANAGER ❑ OTnERAuTnoRIZEDAcENT® CL�NT�A-c.TO 2 <br /> l/.I1,1,i.1 ',IN/,is not the Bli,i,ING I'ARI T,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 ENVIRONMIiN-IAI.HEALTH DFPAR'I'MI-At,as soon as it is available and at the same time it is <br /> provided to me or my representative. PAYMENT <br /> TYPE OF SERVICE REQUESTED: nA LL-)1 PLAe&VV ANT' RECEIVED <br /> COMMENTS: <br /> Replaced MLLD during Annual Monitor Certification with Muni onsite. JAN 6 20 <br /> 0 <br /> 9 <br /> 99LD-2000 NEW SER#08121049 (Replaced like for like) SAN ONIN COUNTY <br /> ENVVIRIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: a� DATE: <br /> ASSIGNED TO: A 1A 4A V EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): 1/0/09SERVICE CODE: z2 7 OF <br /> Fee Amount: Amount Paid Payment ate to Z) <br /> Payment Type Invoice# Check# O Received By: N-?, <br /> ? <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />