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SAN JOAQUII-,,:OUNTY ENVIRONMENTAL HEALTH ><.�PARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID # SERVICE REQUEST # GDF PHONE # EXT. SK 00&A_3,2,�3 OWNER / OPERATOR Lawrence Wright 209 943-3000 CHECK if BILLING ADDRESS ❑ FACILITY NAME Arco AM/PM FAX # PO Sox 55105 SITE ADDRESS 130' ( 209) 943-3003 Wilson Way I STATE CA ZIP 95205 Stockton 95205 Street Number Direction Street Name city Zip Code HOME or MAILING ADDRESS (If Different from Site Address) Street Number Street Name CITY STATE CA ZIP PHONE #1 EXT. APN # LAND USE APPLICATION # ( 209) 466-6633 PHONE #2 EXT. BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR Carl Wayne Henderson CHECK if BILLING ADDRESS® BUSINESS NAME APEC ACCEPTED BY: C) L l U ( PHONE # EXT. DATE: 1 ASSIGNED TO: w O N I" 209 943-3000 HOME or MAILING ADDRESS Date Service Completed (if already completed): 4/12/11 FAX # PO Sox 55105 P 1 E: O ( 209) 943-3003 CITY Stockton STATE CA ZIP 95205 BILLING ACKNOWLEDGEMENT: 1, the undersigned property )r 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. 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 COUNTY Ordinance Codes, Standards, STATE and FEDERAL laws. APPLICANT'S SIGNATURE: C -� �-- / DATE: 4/13/11 PROPERTY/BUSINESS OWNER OPERATOR /MANAGER ❑ OTHER .AtITHORIZEDAGENT ® Technician lfAPPe/CanT is not the BILLI..NG PARTY, proof of authorization to sign is required Title AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, 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: (.4S7- l A rycY I? -- COMMENTS: Replaced PLLD transducer at 87 -master STP (Q-2). PAYMEp RECEIVE OR132 A JO AONME WEN ACCEPTED BY: C) L l U ( EMPLOYEE #: 3 Z N DATE: 1 ASSIGNED TO: w O N I" Eh1PLOYEE #: DATE: t� f3l ( ft Date Service Completed (if already completed): 4/12/11 SERVICE CODE: / P 1 E: O Fee Amount: Amount Paid ©p r Payment Date Payment Type Invoice # Check # R eiveclBy: EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003