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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY/ID# SERVICE REQUEST# r GDF 3 1 3;2. 6;/2 Od lv 1/5-0 2 OWNER/OPERATOR B S. Angle CHECK if BILLING ADDRESS❑ FACILITY NAME Freeway Shell SITEADDRESS 7700 Moreland Ct Stockton 95212 Street Number I Direction I Street Name CitV Zip Code HOME or MAILING ADDRESS (If Different from Site Address) Street NumberT Street Name CITY STATE CA ZIP PHONE#1 EXT. APN# LAND USE APPLICATION# ( 209 ) 957-5398 PHONE#2 EXT. BOS DISTRICT11 OCATION CODE Ir ( ) CONTRACTOR / SERVICE REQUESTOR REQUESTOR Carl Wayne Henderson CHECK if BILLING ADDRESS® BUSINESS NAME PHONE# EXT. Service Station Testing - SST INC 209 465-5577 HOME or MAILING ADDRESS FAX# PO Box 31465 ( 209 ) 465-4988 CITY Stockton STATE CA ZIP 95213 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 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' '_ N — DATE: 3/3/12 PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT O President If APPLICANT is not the B11.1,1.vc PARTT',proof of authorizationto sign is required Title AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, 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: COMMENTS: H8 (dead battery) crash. Replaced battery, restored from archive, hose mapped and operability qWpkfLqALL liquid &vacuum sensors. RECEIVED MAR 0 5 2012 SAN JOAQUPN COUNTY ENVIRONMENTAL ACCEPTED BY: 1 h��' EMPLOYEE M G�Q DATE: - S Z ASSIGNED TO: 6AC&,�l5 EMPLOYEE#: ` �3k DATE: 3 j t Z Date Service Completed (if already completed): 3/2/12 SERVICE CODE: J ��% P I E:. U' Fee Amount: XF,c UV Amount Paid i's75-- C, Payment Date 5-112 Payment Type ✓ Invoice# Check# 1 Received By: EHD 48-02-025 SR FORM(Goldeno REVISED 11/1712003