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SAN JOAQUIN OUNTY ENVIRONMENTAL HEALTHEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />CHECK if BILLING ADDRESS® <br />SERVICE REQUEST # <br />HMC -Henderson Maintenance Company <br />00 <br />PHONE # EXT. <br />209 467-7573 <br />51� <br />OWNER / OPERATOR <br />ec <br />,� 9 2p09 <br />FAX # <br />( 209) 465-4988 <br />Bob Lutz <br />AUG <br />CHECK If BILLING ADDRESS <br />FACILITY NAME EI Dorado Shell <br />AQP\N CtitA�- <br />ACCEPTED BY: <br />SITE ADDRESS 2320 <br />N <br />EI Dorado St <br />ASSIGNED TO: <br />EMPLOYEE #: d f �j �Z ,? <br />7 <br />Stockton <br />95209 <br />Street Number <br />Direction <br />Fee Amount:!Z,ML <br />Street Name <br />D <br />cityD <br />Code <br />Payment Type I/'fCAW{ <br />I Invoice # <br />Check # 1 bgL (I ` 13I � <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Street Number <br />Street Name <br />CITY <br />STATE CA ZIP <br />PHONE #1 EXT. <br />APN # <br />LAND USE APPLICATION # <br />( 209) 943-1311 <br />PHONE #2 EXT. <br />( ) <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />Carl Wayne Henderson <br />CHECK if BILLING ADDRESS® <br />BUSINESS NAME <br />HMC -Henderson Maintenance Company <br />PHONE # EXT. <br />209 467-7573 <br />HOME or MAILING ADDRESS <br />PO Box 31325 <br />ec <br />,� 9 2p09 <br />FAX # <br />( 209) 465-4988 <br />CITY Stockton <br />AUG <br />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 laws. q <br />APPLICANT'S SIGNATURE: DATE: <br />PROPERTY/ BUSINESS OWNER❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT ® Contractor <br />/f 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 19 <br />provided to me or my representative. <br />TYPE OF SERVICE REQUESTED: TANK RETROFIT <br />COMMENTS: Replaced L-4 (91 product) 794380-303 annular space sensor due to intermittent SENSOR OUT alarmsN.� <br />pC �v�D <br />ec <br />,� 9 2p09 <br />AUG <br />AQP\N CtitA�- <br />ACCEPTED BY: <br />EMPLOYEE M l <br />DATE: d <br />ASSIGNED TO: <br />EMPLOYEE #: d f �j �Z ,? <br />7 <br />DATE: <br />Date Service Completed (if already completed): 8/17/09 <br />SERVICE CODE: <br />P / E: 2-309 <br />Fee Amount:!Z,ML <br />Amount Paid <br />D <br />Payment Date <br />g <br />Payment Type I/'fCAW{ <br />I Invoice # <br />Check # 1 bgL (I ` 13I � <br />Received By: <br />EHD 48-02-025 C �. D SR FORM (Golden Rod) <br />1 REVISED 11/17/2003 <br />