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SAN JOAQUI*UNTY ENVIRONMENTAL HEALTI PARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVIC REQUEST# <br /> Hospital orjb 2d � o�� � <br /> W <br /> OWNER/OPERATOR Jacob Wiebe CHECK if BILLING ADDRESS❑ <br /> FACILITY NAME Dameron Hospital <br /> SITE ADDRESS 525 W Acacia St Stockton 95203 <br /> Street Number I Direction I Street Name city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE CA ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> PHONE#Z ExT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR Carl Wayne Henderson CHECK if BILLING ADDRESS® <br /> BUSINESS NAMEPHONE# EXT. <br /> Service Station Testing -SST INC 303541 209 465-5577 <br /> HOME or MAILING ADDRESS FAX# <br /> PO Box 31465 (209 ) 465-4988 <br /> CITY Stockton 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 I 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 FEDERAL laws. <br /> APPLICANT'S SIGNATURE: � / ,--- DATE: 2/14/13 ` <br /> PROPERTY/BUSINESS OWNER[3 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. WMENT <br /> TYPE OF SERVICE REQUESTED: TANK RETROFIT RECEWEED <br /> COMMENTS: Replace diesel spill bucket, drop tube, test installation and diesel MLLD. FEB 15 2013 <br /> SAN JOAQUIN COUNTY <br /> ENVIROMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: C EMPLOYEE M DATE: <br /> ASSIGNED`r0: o EMPLOYEE M DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P/E: . <br /> Fee Amount: 2 Amount Paid 'f 3-75 Payme Date 2l/ <br /> Payment Type invoice# Check# 1 z i 0 q Received By: L'e-) <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 (f7 <br />