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SAN JOAQUO COUNTY ENVIRONMENTAL HEALTHPARTMENT SERVICE REQUEST Type of Business or Property GDF FACILITY ID # 15 BUSINESS NAME Service Station Testing -SST INC SERVICE REQUEST # 5 k-Ov 0 3 OcY�� OWNER / OPERATOR HOME or MAILING ADDRESS PO Box 31465 CHECK If BILLING ADDRESS FACILITY NAME 76 Manteca CITY Stockton STATE CA ZIP 95213 SITEADDRESS 1700 Street Number E Direction Yosemite Ave I Street Name DATE: `7 a Manteca city 95366 Zip Code HOME or MAILING ADDRESS (If Different from Site Address) Street Number SERVICE CODE: Street Name CITY Fee Amount: O v STATECA ZIP PHONE #1 EXT. APN # Payment Type LAND USE APPLICATION # PHONE #2 EXT. Received By: BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR Carl Wayne Henderson CHECK if BILLING ADDRESS® BUSINESS NAME Service Station Testing -SST INC JUL 2 2 201 PHONE # EXT. 209 465-5577 HOME or MAILING ADDRESS PO Box 31465 FAX# ( 209 ) 465-4988 CITY Stockton STATE CA ZIP 95213 BILLING ACKNOWLEDGEMENT: 1, 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. 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: Go✓(' t^- • /� DATE: PROPERTY/BUSINESS OWNER❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT® President if APPLICANT IS not the BILLING PARTY, proof Of authorization t0 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: pA,Y COMMENTS: Certify 91 MLLD (could not test during annual Monitor Certification. JUL 2 2 201 Certify 87 MLLD (No permit pulled when originally replaced) SAN JOAQUIN COUNTY "*** DOUBLE PERMIT FEE "'* ENVIRONMENTAL DEPARTMENT HEALTH ACCEPTED BY: EMPLOYEE #: 9Cris DATE: `7 a ASSIGNED TO: EMPLOYEE #: �(p (�� I DATE: �� ) Date Service Completed (if already comple SERVICE CODE: P / E.,2 k Fee Amount: O v Amount Paid jap 3�, p Payment Date `Z Payment Type Invoice # Check # l Z,� 3 Received By: EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003