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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> GDF till sl-coo & YO';e <br /> OWNER/OPERATOR <br /> CHECK if BILLING ADDRESS <br /> FACILITY NAME MacArther Chevron <br /> ,SITEADDRESS 3400 N I MacArther 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 /> Cm STATE CA Zip <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> ( 209 ) 834-1220 <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 /> Service Station Testing-SST INC 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 FEDE L/laws. <br /> APPLICANT'S SIGNATURE: lam.( T-- ^' DATE: 9/6/11 <br /> PROPERTY/BUSINESS OWNER 13 OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT® President <br /> 1fAPPL/CANT is not the BELLLNG 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. q <br /> TYPE OF SERVICE REQUESTED: I'/ ( PAY <br /> COMMENTS: EMERGENCY Sensor replacement expected 9/6/11 late afternoon (when part arrives). E(VED <br /> SEP - 6 2011 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: O Lt VE.t II EMPLOYEE#: C)b14 <br /> DATE: <br /> ASSIGNED TO: ^7 „1 EMPLOYEE M 2& DATE: 6 <br /> Date Service Completed (if already completed): SERVICE CODE: L O PIE: <br /> Fee Amount: 3')S'_ Amount Paid �ZS Payment Date � f7 rf <br /> Payment Type 0tx4EC C_ Invoice# Check# 135 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />