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r <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT W <br /> SERVICE REQUEST <br /> Type of Business or Property F CIIrLII1T�Y ID# SERVICE REQUEST# <br /> GDF '1 dlJ 60 <br /> OWNER/OPERATOR Rick Grewal <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME AGP-GREWALS GAS& LIQUOR <br /> SITE ADDRESS 4100 1 E Fremont St Stockton 95215 <br /> Street Number 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 /> ( 209 ) 463-5294 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR Carl Wayne Henderson 405016 <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> Service Station Testing- SST INC/CSLB 962520 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 FEDERALIaWS. <br /> APPLICANT'S SIGNATURE: DATE: 6/12/14 <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT® President <br /> If APPLICANTis 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. POMENT <br /> TYPE OF SERVICE REQUESTED: 1 , 17-.;1,96 <br /> COMMENTS: <br /> H-8 ATG crash. JUN 12 2014 <br /> Replaced battery, restored from archive and checked operation. SAN JOAOUIN COUNTY <br /> ENVIROMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED B EMPLOYEE#: DATE: <br /> ASSIGNED TO: ©� - EMPLOYEE#: DATE: 3— <br /> Date Service Completed (if already completed): 6/10/14 1 <br /> SERVICE CODE: P I E: <br /> Fee Amount: X17 S'— Amount Paid 82J---00 Payment Date Ile <br /> Payment Type Invoice# Check 111 —7—2 geceiveld By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br /> O <br /> ' " y <br />