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SAN JOAQUI . yOUNTY ENVIRONMENTAL HEALTH IPPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> GDF i2=b6 ,ecobby� <br /> OWNER/OPERATOR Jessie <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME ARCO- Manteca <br /> SITEADDRESS 1100 S Main Street Manteca 95337 <br /> Street Number Direction Street Name Cit Zi 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 ► 825-6784 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR Carl Wayne Henderson 203378 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: 1, 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 1 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 FERE L laws. <br /> APPLICANT'S SIGNATURE: l� L—� _ 7� DATE: 12/17/12 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT® President <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1,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. A <br /> TYPE OF SERVICE REQUESTED: TANK RETROFIT REPAIR <br /> COMMENTS: Replaced defective 323 sensor with 208 at L-7 (87 STP Sump). Updated Monitoring Plan and sg{bmi -t � o <br /> permit application. -44( 1 7 <br /> tiF FN°goct, <br /> A<Ty�OaAT UN�Y <br /> M NT <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DAT : <br /> Date Service Completed (if already completed): 12/16/12 SERVICE CODE: P/E: <br /> Fee Amount: Amount Paid 375�Q Paym nt Date <br /> Payment Type Invoice# Check# 12-o Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />