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L6"�) <br />SAN JOAQUOOUNTY ENVIRONMENTAL HEALTH11PARTMENT ORIGINAL <br />SERVICE REQUEST <br />Type of Business or Property <br />GDF <br />FACILITY ID # <br />'l t <br />BUSINESS NAME <br />Service Station Testing -SST INC / C��LB 962520 <br />SERVICE REQUEST # <br />,�%� 6 v 7 ) -tG <br />OWNER/ OPERATOR Paul Singh <br />HOME or MAILING ADDRESS <br />PO Box 31465 <br />CHECK if BILLING ADDRESS❑ <br />FACILITY NAME Parkwoods Shell <br />CITY Stockton <br />STATE CA Zip 95213 <br />SITEADDRESS 1612W <br />Street Number <br />Direction <br />Hammer Ln <br />I <br />Street Name <br />ACCEPTED BY: <br />Stockton <br />city <br />95209 <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Street Number <br />EMPLOYEE #: <br />Street Name <br />CITY <br />Date Service Completed (if a easy completed): 1/26/15 <br />STATE CA ZIP <br />PHONE #1 EXT. <br />( ) <br />APN # <br />Amount Paid 3-7/6) <br />LAND USE APPLICATION # <br />PHONE #2 EXT. <br />Invoice # <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR Carl Wayne Henderson 505339 <br />CHECK if BILLING ADDRESS® <br />BUSINESS NAME <br />Service Station Testing -SST INC / C��LB 962520 <br />JgN2�/��O <br />PHONE# EXT. <br />209 465-5577 <br />HOME or MAILING ADDRESS <br />PO Box 31465 <br />FAX # <br />( 209 ) 465-4988 <br />CITY Stockton <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 FED <br />APPLICANT'S SIGNATURE: C--"( :�Z— <br />t--�DATE: 1/26/15 <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. w <br />TYPE OF SERVICE REQUESTED: <br />COMMENTS: Replaced diesel MLLD due to tripping at 18 PSI. <br />JgN2�/��O <br />SqN <br />Q <br />h►Fq�T <br />f �Hco%S <br />OFA <br />qr � �Y <br />ACCEPTED BY: <br />EMPLOYEE #: <br />DATE: L <br />ASSIGNED TO: <br />EMPLOYEE #: <br />DATE: <br />Date Service Completed (if a easy completed): 1/26/15 <br />SERVICE CODE: <br />P I E: (� <br />Fee Amount: <br />Amount Paid 3-7/6) <br />Payment Date 1/2,7tt <br />Payment Type <br />Invoice # <br />Check # �! ey <br />Received By: C <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />