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SAN JOAQUII, %:OUNTY ENVIRONMENTAL HEALTH i EPARTMENTLJ ONGINU <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />BUSINESS NAME <br />Service Station Testing -SST INC / CSLB 962520 <br />SERVICE REQUEST # <br />GDF <br />HOME or MAILING ADDRESS <br />PO Box 31465 <br />OWNER/ OPERATOR B & G Group, Inc. <br />CITY Stockton <br />CHECK if BILLING ADDRESS ❑ <br />FACILITY NAME FAST LANE - Lathrop <br />SITEADDRESS 116 <br />RothE Rd <br />SA E <br />pA'I� <br />DE <br />Lathrop <br />95330 <br />Street Number <br />Direction <br />EMPLOYEE #: <br />Street Name <br />ASSIGNED TO: � ,,, , f <br />city <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Date Service Completed (if already completed): 2/2/15 <br />SERVICE CODE: ly lf <br />P 1 E:;Z-v <br />Street Number <br />Street Name <br />CITY <br />STATE CA ZIP <br />PHONE #1 EXT. <br />APN # <br />Check # p J t 9'j O <br />LAND USE APPLICATION # <br />1 209 1 234-4341 <br />PHONE #2 ExT. <br />( 1 <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR Carl Wayne Henderson S*off;~ 3 Lo 4 <br />CHECK if BILLING ADDRESS® <br />BUSINESS NAME <br />Service Station Testing -SST INC / CSLB 962520 <br />COMMENTS: H-8 alarm: COLDSTARTED Truck side TLS -350 due to dead battery crash. <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 F7w�- <br />APPLICANT'S SIGNATURE: �e� �. DATE: 2/3/15 <br />PROPERTY / BUSINESS OWNER❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT <br />If APPLICANT is not the BILLING PARTY proof of authorization to sign is required <br />President <br />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. —Wamr <br />TYPE OF SERVICE REQUESTED: <br />UST c-4�i % — <br />PA <br />COMMENTS: H-8 alarm: COLDSTARTED Truck side TLS -350 due to dead battery crash. <br />4 3 2015 <br />FEB <br />( <br />ALARM HISTORY WAS LOST004 <br />couto <br />OAAp <br />SA E <br />pA'I� <br />DE <br />H�'TH <br />ACCEPTED BY <br />EMPLOYEE #: <br />DATE: r <br />ASSIGNED TO: � ,,, , f <br />EMPLOYEE #: <br />,�r <br />DATE: �J <br />Date Service Completed (if already completed): 2/2/15 <br />SERVICE CODE: ly lf <br />P 1 E:;Z-v <br />Fee Amount: <br />Amount Paid 3q C) Ce <br />Payment Date <br />S <br />Payment Type ,, <br />Invoice # <br />Check # p J t 9'j O <br />Received By <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />