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14111111 SAN JOAQU i COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST � oRtcnvnL Type of Business or Property FACILITY ID 111 SERVICE REQUEST # GDF si"t HOME Or MAILING ADDRESS PO Box 31465 OWNER/ OPERATOR Sukhwinder Singh CHECK If BILLING ADDRESS FAciurr NAME Fast N Easy STATE CA ZIP 95213 SITEADDRESS 244W Harding Way Stockton 95204 Street Number Direction t A 3 Street Name ciw Zip Code HOME Or MAILING ADDRESS (If Different from Site Address) Payment Date (Qt O 1 ILL Payment Type S[ree[ Number Street Name CITY STATE CA ZIP PHONE #1 EXT. APN# L,� LAND USE APPLICATION # ( 209 )954-2548 PHONE #2 EXT. BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR Carl Wayne Henderson CHECK If BILLING ADDRESS® BUSINESS NAME Service Station Testing - SST INC / CSLB 962520 COMMENTS: Removed damaged TLS -350 and installed TLS -300C. Programmed and checked operation PHONE# EXT. 209 1 465-5577 HOME Or MAILING ADDRESS PO Box 31465 FAX # ( 209 1 465-4988 CITY Stockton STATE CA ZIP 95213 BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as identified on this form. 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 COUNTY Ordinance Codes, Standards, STATE and FEDERAL laws. APPLICANT'S SIGNATURE: r" t_ - "�RA— DATE: 6/9/14 PROPERTY/ BUSINESS OWNER 13 OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT® President IfAPPLICANT is not the BauNG PARTY proof of authorization to sign is required True AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. TYPE of SERVICE REQUESTED: wT COMMENTS: Removed damaged TLS -350 and installed TLS -300C. Programmed and checked operation SUN Q Z��4 SAN JOAQUIN COUNTY PNVIROMENTAL b'ALTH BE ARTMENT ACCEPTED BY: (7 L v ty,� EMPLOYEE M DATE: T ASSIGNED TO: W.pk EMPLOYEE#: DATE: Date Service Completed (if already completed): 6/8/14 SERVICE CODE: t A 3 PIE: Fee Amount: - -1, 5 Amount Paid 3-1 S , o -p Payment Date (Qt O 1 ILL Payment Type Invoice # Check # O L L-1 (p—] Received By: EHD 48-02-025 REVISED 11/17/2003 ) , V [ �-e' SR FORM (Golden Rod) looly l