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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH Lr�PARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID # SERVICE REQUEST # GDF PHONE # ExT• Walton Engineering, Inc. Need to replace the OPW, 87 direct OWNER / OPERATOR 373-1165 HOME or MAILING ADDRESS Tracy 76 Reliance Gas Investments CHECK If BILLING ADDRESS FACILITY NAME P.O. Box 1025 EMPLOYEE #: Tracy 76 373-1173 CITY West Sacramento SITE ADDRESS 2420 West Grantline Road Fee Amount: ft Tracy 95377 Street Number Direction Street Name Payment Type ✓� - Ci Zip Code HOME or MAILING ADDRESS (If Different from Site Address) Street Number Street Name CITY STATE ZIP PHONE #1 Exr. APN # LAND USE APPLICATION # (209)830-1139 PHONE #2 ( ) ExT• BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR Tanya Thompson CHECK if BILLING ADDRESS 0 BUSINESS NAME chainittLlin p PHONE # ExT• Walton Engineering, Inc. Need to replace the OPW, 87 direct 916 373-1165 HOME or MAILING ADDRESS ACCEPTED BY: FAX # DATE: P.O. Box 1025 EMPLOYEE #: (916) 373-1173 CITY West Sacramento STATE CA ZIP 95691 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 applica 'on anq that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, Standards,STA and ERAL laws. APPLICANT'S SIGNATURE: �� , �/�� DATE: 05-17-12 PROPERTY/ BUSINESS OWNER❑ OPERATOR/ MANAGER 0 OTHER AUTHORIZED AGENT ❑ If APPLICANT is not the BILLING PARTY_proof of authorization to sign is required Title AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at tl� above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/siteI' �aassessme Z information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at thk afftE ti&6 it < provided to me or my representative. Z o v Z TYPE OF SERVICE REQUESTED: cv COMMENTS: Replaced with like -for -like equipm t, the float and chainittLlin p Di#1/2 UDC, and the annular sensor in both UST #1 and #2/F-duri the MSC performed on 05/17/12. Need to replace the OPW, 87 direct bury sp1 bucket ACCEPTED BY: EMPLOYEE #: <F DATE: ASSIGNED TO: EMPLOYEE #: DATE: Date Service Completed falreadly completed): SERVICE CODE: P 1 E: Fee Amount: ft Amount Paid Payment Date Cj ZZ Payment Type ✓� - Invoice # Check # 1 Received By: k EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003 �a aW Z J a LJ