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SAN JOAQUI OUNTY ENVIRONMENTAL HEALTAPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITYID# SERVICE REQUEST# <br /> GDF 3 l l 7 <br /> OWNER/OPERATOR Van de Pol Enterprises Inc CHECK if BILLING ADDRESS❑ <br /> FACILITY NAME Pacific Pride <br /> SITEADDRESS 351 IN I Beckman Rd Lodi 95240 <br /> Street Number Direction Street Name I city I Zi 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 /> ( ) t% q f_CJC--ls'_ <br /> PHONE#2 EXT_ BOS DISTRICTCAN CODE <br /> IffTIO2— <br /> CONTRACTOR <br /> It 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 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: L6--"( '— /-/— DATE: 6/25/10 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT® Contractor <br /> If APDL/CANT 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. t„(S-r oalg-7-e-a F iT <br /> TYPE OF SERVICE REQUESTED: TANK RETROFIT <br /> COMMENTS: Replaced defective 208 sensor in Vent Sump (L-16)discovered 6/25/2010. RECEIVED <br /> JUN 2 8 2090 <br /> SAN JOAQUINEN\nROCOUNTY <br /> HEALTH►DEPMAFlTIJIENT <br /> ACCEPTED BY: EMPLOYEE#: 1, DATE: <br /> ASSIGNED TO: � � /� ( EMPLOYEE#: , 4 2--2-- DATE: 6 2 r o <br /> Date Service Completed (if already completed): 6/25/10 SERVICE CODE: r go P/E:2 10 e <br /> of <br /> Fee Amount: . Amount Paid 3y s Payment Date <br /> Payment Type ✓ Invoice# Check# O ` Z Received By: N'r <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />