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SAN JOAQUI r COUNTY ENVIRONMENTAL HEALTH iiEPARTMENT ORIGINAL SERVICE REQUEST Type of Business or Property FACILITY ID # BUSINESS NAMEPHONE# Service Station Testing -SST INC / CSLB 962520 SERVICE REQUEST # GDF HOME Or MAILING ADDRESS 6P00-7-2-(0 OWNER/ OPERATOR PO Box 31465 CHECK if BILLING ADDRESS FACILITY NAME Fast Lane CITY Stockton STATE CA ZIP 95213 SITE ADDRESS 116 E Roth Rd P / E: (fg Lathrop F�30Street Number Direction Type Street Name Check #2 -Di Ci i Code HOME or MAILING ADDRESS (If Different from Site Address) Street Number Street Name CITY STATE CA ZIP PHONE #1 EXT. APN # LAND USE APPLICATION # ( 209 ) 234-4341 PHONE #2 EXT. ( ) BOS DISTRICT LOCATION CODE CONTRACTOR/ SERVICE REQUESTOR REQUESTOR Carl Wayne Henderson 505546 CHECK if BILLING ADDRESS® BUSINESS NAMEPHONE# Service Station Testing -SST INC / CSLB 962520 SAN JO E'V EXT. 209 465-5577 HOME Or MAILING ADDRESS FAX # PO Box 31465 ( 209 ) 465-4988 CITY Stockton STATE CA ZIP 95213 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 SIGNATURE: C--'� w - t1-1-- DATE: 7/8/15 PROPERTY/BUST NESS OWN ER 13 OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT® IfAPPLICANT APPLICANT is not the BILLING PARTY, proof of authorization to sign is required President 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 environmentallsit assessment information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the s�i/I�. . 71 provided to me or my representative. R ft r•,rN TYPE OF SERVICE REQUESTED: COMMENTS: Cleaned dirt & debris from auto side sump collars. SAN JO E'V Cleaned, sealed &lubricated vapor sump covers. coij NF CrH R Mp'V-rA L Rrlw Adjusted OVERFILL from 90 to 95% & HIGH PRODUCT from 95 to 90%. ACCEPTED BY: MPLOYEE #: O r DATEAAA ASSIGNED TO: J'EMPLOYEE #: DATE: Date Service Completed (if already completed): 7/7/15 SERVICE CODE: ti !of P / E: (fg unt: �(�.OD "Payment Amount Pa �czO U� Payment Date % Type Invoice # Check #2 -Di Rec Ived By: EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003 VTy VT