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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> 0 SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> GDF j-A-0 0 16 7 3 S Zoo V 7"7,s?,-X <br /> OWNER/OPERATOR Boyett Petroleum CHECK if BILLING ADDRESS❑ <br /> FACILITY NAME Valero- Manteca <br /> SITEADDRESS 1137W Lathrop Rd Manteca 95337 <br /> Street Number Direction Street Name city Zip 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 ) 824-2760 Z 0 — 0 Z <br /> LOCATION CODE <br /> PHONE#2 EXT. BOS DISTRICT <br /> ( ) & <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR Carl Wayne Henderson 304183 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 /> CIN Stockton STATE CA ZIP 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 /> 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 <br /> COUNTY Ordinance Codes,Standards,STATE and FEDERAL <br /> laws. <br /> APPLICANT'S SIGNATURE: Cl--( L✓. ` DATE: 8/10/13 <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, 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: UST f t-k <br /> COMMENTS: Replaced defective 208 sensor at#3/4 UDC (L-11). RECEIVED A 0 1 ,5 <br /> AUG 2 8 2013 SAN'/OAQUI 2013 <br /> SAN JOAQUIN COUNTY HE HOklvvll�F� NTglNTY <br /> ENVIROMENTAMFNT <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE M -2— 70 DATE: <br /> ASSIGNED TO: G � EMPLOYEE M e70 v DATE: <br /> Date Service Completed (if already competed): 8/9/13 SERVICE CODE: j Cl 9 PIE: 2 3 <br /> Fee Amount: 37 5- Amount PaidIP37L5 Payment Date r� g <br /> Payment Type I/ Invoice# Chec # III3 l Received Bi. <br /> EHD 48-02-025 ` " ` SR FORM Golde od) <br /> REVISED 11/17/2003 <br />