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SAN ,IOAQUIPOUNTY ENVIRONMENTAL HEALTH 1Lr..rARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> GDF -3 (ve=1 JA(_'C'.S 7'__)­� �— <br /> OWNER/OPERATOR Bobbie CHECK if BILLING ADDRESS❑ <br /> FACILITY NAME 76 Express ( Formerly KWIK SERV) <br /> SITEADDRESS 419S Main Manteca 95366 <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 At LAND USE APPLICATION# <br /> ( 209 ) 401-5181 3A-6^-(U <br /> PHONE#2 EXT. BOS DISTRICT /� LOCATI CODE <br /> ( ) G <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR Carl Wayne Henderson CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE EXT. <br /> HMC - Henderson Maintenance Company 209 467-7573 <br /> HOME or MAILING ADDRESS FAX# <br /> PO Box 31325 ( 209 ) 465-4988 <br /> CITY Stockton STATE CA ZIP 95213 <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowled-e that all site and/or project specific ENVIRONMEN FAL HFAI.nl DFI)ARI'MFINI 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 I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> Cot IN FY 01-din11/7Ce('udeS,Standards,SI'ATI:and FEDI;RAI. laws. Q <br /> APPLICANT'S SIGNATURE: � / D,t l-p:: 'S <br /> PROPER11/[it SINESSO%NNER❑ OPERA IOR/ ❑ OIIiF:RAI"InORIZEDAGENI ® Contractor <br /> /J.li'Pl./(,I\'7 i.s lint the R//././\(./'.IK7),proof of'authorization to sh;n is require[/ 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 COUNI)' F,NVIRtmMFN]A] tIFAI Tll DI:PARIMI[NI 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: Piping Retrofit (AST /- /L PAYMEN <br /> COMMENTS: Replaced 87 MLLD found defective during annual monitor certification. Inspector was oni e_ , D <br /> 2009 <br /> SAN JOAQUIN C <br /> HEAENViDE MEfOUNV�'gE 7Y <br /> ARTWNT <br /> ACCEPTED BY: f'T ``� t EMPLOYEE#: D 3 DATE: <br /> ASSIGNED TO: J%J L D EMPLOYEE#: DATE: t tJ <br /> Date Service Completed (if already completed): 5/8/09 SERVICE CODE: (� PIE: 23D& <br /> Fee Amount: _ 3 iSv>} Amount Paid Payment Date /,( <br /> Payment Type Invoice# Check# let Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />