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SAN JOAQUO, COUNTY ENVIRONMENTAL HEALT ,vPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> GDF �z f-v 67 Al <br /> OWNER/OPERATOR Rick Grewal CHECK if BILLING ADDRESS <br /> FACILITY NAME AGP-GREWALS GAS& LIQUOR <br /> SITE ADDRESS 4100 E I Fremont St Stockton 95215 <br /> Street Number Direction Street Name cily 2i ode <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 REQUEST R <br /> REQUESTOR Carl Wayne Henderson 405016 CHECK if BILLING ADDRESS <br /> BUSINESS NAMEPHONE# 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 usiness owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific ENVIRONMENTAL HE TH DEPARTMENT hourly charges associated with this project <br /> or activity will be billed to me or my business as identified on this fo <br /> I also certify that I have prepared this application and that the wor 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: 6/12/14 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGE OTHER AUTHORIZED AGENT President <br /> /f APPLICANT is not the BILLING PARTY,pr f of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATI : When applicable,I,the owner or operator of the property located at the <br /> above site address, hereby authorize the release any and all results, geotechnical data and/or environmental/site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRON TAL 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: <br /> COMMENTS: <br /> H-8 ATG crash. <br /> Replaced battery, restore from archive and checked operation. <br /> ACCEPTED BY: EMPLOYEE M DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if .ready completed): 6/10/14 SERVICE CODE: P I E: <br /> Fee Amount: Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />