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SAN JOAQUI OUNTY ENVIRONMENTAL HEALTT-T nEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> GDF (✓ I Z C� j GCS (- -7-7 -y3 <br /> OWNER/OPERATOR Love's Travel Stops CHECK if BILLING ADDRESS❑ <br /> FACILITY NAME Love's-Store 223- Ripon <br /> SITEADDRESS 1553W Colony Rd Ripon 95366 <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 /> CITY STATE CA ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> ( 209 ) 599-0740 'Z4 5— 3y 0 — 2- 4 <br /> PHONE#2 EXT. BOS DISTRICTLOCATION 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 ag f same, <br /> acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated wi t,T <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 Qh all's gJAQ�I1�'' <br /> Af <br /> COUNTY Ordinance Codes,Standards, STATE and FEDERAL laws. O NIP <br /> APPLICANT'S SIGNATURE: �--.�� 8/14/13 hE 4t1y00�,1F CONN <br /> APPL DATE. N jy <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT® President T4iF1Vr <br /> If APPL/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. <br /> TYPE OF SERVICE REQUESTED: u S <br /> COMMENTS: Replace High Capacity Mechanical Leak D tector, discovered during annual monitor certification 8-13-2013. <br /> ACCEPTED BY: (1� lu l�ti� EMPLOYEE#: V DATE: ( � ' <br /> ASSIGNED TO: EMPLOYEE#: DATE:Tb <br /> 6 <br /> Date Service Completed (if already completed): SERVICE CODE: i G� � PIE: <br /> Fee Amount: 3 7 S �--- Amount Pai 375= Payments Date, <br /> Payment Type %, Invoice# Check# )/,52 Recteived By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />