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SAN JOAQUi-COUNTY ENVIRONMENTAL HEALTH17CPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />SERVICE REQUEST # <br />GDF <br />PHONE# En. <br />209 465-5577 <br />HOME or MAILING ADDRESS <br />PO Box 31465 <br />OWNER/OPERATOR Sukhwinder Singh <br />CHECK H BILLING ADDRESS <br />FACILITY NAME Fast N Easy <br />STATE CA LP 95213 <br />SITE ADDRESS 244 <br />W <br />I <br />Harding Way <br />ACCEPTED BY: <br />Stockton <br />95204 <br />Street Number <br />Direction <br />DATE: <br />Street Name <br />coZip <br />Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Fee Amount: '3"l5' .crD <br />Amount Paid �, 3—lb <br />Payment Date <br />S[ree[ Number <br />Street Name <br />CITY <br />STATE CA Zip <br />PHONE #1 Em <br />APN # <br />LAND USE APPLICATION # <br />( 209 ) 954-2548 <br />PHONE tit Em <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR Carl Wayne Henderson <br />CHECK if BILLING ADDRESS® <br />BUSINESS NAME <br />Service Station Testing - SST INC / CSLB 962520 <br />RECEIVED <br />PHONE# En. <br />209 465-5577 <br />HOME or MAILING ADDRESS <br />PO Box 31465 <br />FAx # <br />( 209 ) 465-4988 <br />CITY Stockton <br />STATE CA LP 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 />1 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 FEDERAL laws. <br />APPLICANT'S SIGNATURE: r'� t� . H� DATE: 6/9/14 <br />PROPERTY/ BUSINESS OWNER❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIzEu AGENT® President <br />If.4PPLICANT 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: <br />PAYAAFNI <br />COMMENTS: Removed damaged TLS -350 and installed TLS -300C. <br />RECEIVED <br />Programmed and checked operation <br />JUN 10 2014 <br />SAN JOAQUIN COUNTY <br />ENVIROMENTAL <br />HEALTH DEPARTMENr <br />ACCEPTED BY: <br />EMPLOYEE #: <br />DATE: <br />ASSIGNED TO: <br />EMPLOYEE #: <br />DATE: <br />Date Service Completed (If already completed): 6/8/14 <br />SERVICE CODE: <br />P/ E: <br />Fee Amount: '3"l5' .crD <br />Amount Paid �, 3—lb <br />Payment Date <br />l l0 <br />LL' <br />Payment Type <br />I Invoice # <br />Check # p t.l -'((01 <br />Received By:-kVC3) <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 ^n/ <br />G� / <br />