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SAN JOAQPCOUNTY ENVIRONMENTAL HEALTREPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID # SERVICE REQUEST # Mike Eliason Ft4 0 d 7 S Qoo s`l- _spa �? OWNER/ OPERATOR CHECK if BILLING ADDRESS® Valley Pacific Petroleum Services, Inc. HOME or MAILING ADDRESS FACILITY NAME Charter Way Cardlock FAX# SITE ADDRESS 1501W 1633 E Mineral Kin Charter Way (559 Stockton 95206 Street Number Direction Street Name city Zip Code HOME or MAILING ADDRESS (if Different from Site Address) 188A Frank West Circle Street Number Street Name CITY STATE ZIP Stockton CA 95206 PHONE #1 EXT. APN # LAND USE APPLICATION # (209 ) 993-8793 PHONE #2T BOS DISTRICT 11 LOCATION CODE (209 ) 948-9412 322 CONTRACTOR / SERVICE REQUESTOR REQUESTOR COMMENTS: SAN JOAQUIN COUNTY ENVIR NMENTAL Repair or replace the sensor in the dispenser #7 satelite UDC. We will first try to reptt�,5119eFITMENT the Bravo float. If that doesn't work we will instal a Veeder Root 847990-001 stand alone despenser pan sensor. The satelite dispenser is currently out of service. ACCEPTED Mike Eliason DATE: `� Z CHECK If BILLING ADDRESS BUSINESS NAME Valley Pacific Petroleum DATE: PHONE# 209 Ext' 993-8793 HOME or MAILING ADDRESS Fee Amount: -3 FAX# Payment Date 3 1633 E Mineral Kin Payment Type , ` s (559 )636-7565 CITY Visalia STATE CA ZIP 93292 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 SIGNATUR]R DATE: 3/12/2010 PROPERTY / BUSINESS OWNER❑ OPERATOR/ MANAGER ® OTHER Au ORIZED AGENT ❑ IfAPPLiCANT is not the B=m'G PARTY, proof of authorization to 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 atF^Yfm wit is provided to me or my representative. RECEIVED TYPE OF SERVICE REQUESTED: Repair/Replace UDC sensor MAR 12 2010 COMMENTS: SAN JOAQUIN COUNTY ENVIR NMENTAL Repair or replace the sensor in the dispenser #7 satelite UDC. We will first try to reptt�,5119eFITMENT the Bravo float. If that doesn't work we will instal a Veeder Root 847990-001 stand alone despenser pan sensor. The satelite dispenser is currently out of service. ACCEPTED EMPLOYEE #: DATE: `� Z ASSIGNED TO: EMPLOYEE #: :3� DATE: Date Service Completed already completed): SERVICE CODE: P / E. Q O S( (/ Fee Amount: -3 Amount Paid 3 s _ Payment Date 3 2-1 10 Payment Type , ` s Invoice # # 0 U Received By: EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003