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SAN JOAQUIIa"l OUNTY ENVIRONMENTAL HEALTHOPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERV <br /> ICE REQUEST# <br /> GDF 0QD �Ct7S- -7 <br /> OWNER/OPERATOR Charanjit"CJ"S Jutla CHECK if BILLING ADDRESS <br /> FACILITY NAME Tracy Truck Stop <br /> SITEADDRESS 3940 1 N Tracy Blvd Tracy 95376 <br /> Street Number Direction Street Name City Zip 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 /> ( 209 ) 832-5006 -Z 11 'ZZ O Q b <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR Carl Wayne Henderson CHECK if BILLING ADDRESS® <br /> BUSINESS NAME PHONE# EXT. <br /> HMC- Henderson Maintenance Company 209 467-7573 <br /> HOME or MAILING ADDRESS FAX# <br /> PO Box 31325 ( 209 ) 465-4988 <br /> CITY 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 ENVIRONMFN'rnL. HrnL.TH DFPARTMF.N'r 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 JOAQUtN <br /> COUNTY Ordinance Codes,S7andards,SIA-1 1:and FF.r)eRAI. laws. <br /> APPLICANT'S SIGNATURE: C q '—,- DATF,: q'i&`o 1G <br /> PROP E.RrY/BIISINESS OWNER❑ OPERATOR/MANAGER ❑ OTHE.RAUTHORiZEDAGENT® Contractor <br /> ff,,I P1,1.1c A,V1'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 COON rY ENVIRONMr:N FAL HEALTH DBPARTMI3N'I 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: RETROFIT <br /> COMMENTS: Replace 2 each existing 3 phase Magnetic Starters with 2 each STP-SCIII's setu `e STP operation. <br /> EXPECTED SERVICE DATE:4/17/09 APR 1 6 2009 <br /> TY <br /> RpNMEN�ANL <br /> iH Ole <br /> ACCEPTED BY: EMPLOYEE#: DATE: 1 0 <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: 1 P/E: <br /> Fee Amount: �� m"� Amount Paid J16— <br /> / — _ Payment Date �� p q <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />