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SAN JOAQUIN L;OUNTY ENVIRONMENTAL HEALTH DARTMENT <br />SERVICE REQUEST <br />Type of Business°or Property <br />CHECK if BILLING ADDRESS® <br />FACILITY ID # <br />SERVICE REQUEST # <br />GDF <br />HOME or MAILING ADDRESS <br />F4 "k fvA 3 <br />5ecb. &8��� <br />OWNER / OPERATOR <br />\ <br />CHECK If BILLING G ADDRESS <br />CITY Stockton <br />STATE CA ZIP 95213 <br />HEALTH DEPARTMENT <br />FACILITY NAME Tracy Valero <br />EMPLOYEE #: <br />SITEADDRESS 2375 <br />ASSIGNED TO: <br />Tracy Blvd <br />Tracy <br />95376 <br />Street Number- <br />Direc 'on <br />Street Name <br />PIE: 2 3y1 <br />CI <br />Zi Code <br />Payment Date <br />Payment TypeInvoice <br /># <br />HOME Or MAILING ADDRESS (if Different from <br />Site Address) <br />Received By: <br />Street Number <br />Street Name <br />CITY., <br />'STATE CA <br />ZIP <br />PHONE #1 EXT. <br />APN # <br />LAND USE APPLICATION # <br />( 209 ) 833-2236 <br />11 <br />Z Z o <br />PHONE #2 ExT• <br />BOS DISTRICT <br />& <br />LOCATION CODE <br />L j <br />CONTRACTOR /`SERVICE REQUESTOR <br />REQUESTOR Carl Wayne Henderson <br />CHECK if BILLING ADDRESS® <br />k:;EiUSINESS NAMEPHONE <br />Service Station Testing -SST INC ! CSLB 962520 <br />D <br /># ExT. <br />209 465-5577 <br />HOME or MAILING ADDRESS <br />L-4 intermittent fuel alarm (407) <br />FAX # <br />PO Box 31465 <br />SAN JOAQUIN COUNTY <br />1209 ) 465-4988 <br />CITY Stockton <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 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 11 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 FEDtRAL laws. <br />APPLICANT'S SIGNATURE: �� t- �/ DATE: 11/26/13 <br />PROPERTY / BUSINESS OWNER ❑ 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, 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 />provided to me or my representative. <br />TYPE OF SERVICE REQUESTED: ' T- , j Ar <br />PAYMENT <br />COMMENTS: ATG CRASH coldstarted and restores from archive. <br />D <br />NOV 2 7 2013 <br />L-4 intermittent fuel alarm (407) <br />SAN JOAQUIN COUNTY <br />ENVIROMENTAL <br />HEALTH DEPARTMENT <br />ACCEPTED BY: i �— Gib <br />EMPLOYEE #: <br />DATE: (� I2 f <br />! <br />ASSIGNED TO: <br />EMPLOYEE #: <br />DATE: <br />Date Service Completed (if already completed): 11125/13 <br />SERVICE CODE: <br />i <br />PIE: 2 3y1 <br />Fee Amount: 3 "� v J <br />Amount Paid 7� .— <br />Payment Date <br />Payment TypeInvoice <br /># <br />Check # . p � L S 4 <br />Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />