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SAN JOAQUP" COUNTY ENVIRONMENTAL HEALTT' DEPARTMENT,- SERVICE REQUEST Type of Business or Property FACILITYID# SERVICE REQUEST # GDF !'T ':Cv4�agVV OWNER/ OPERATOR FAX# ( 209 ) 465-4988 CITY Stockton CHECK If BILLING ADDRESS ❑ FACILITY NAME Fast Lane SAN JOAQUIN COUNTY SITE ADDRESS 100 E Roth Lathrop 95330 Street Number Direction EMPLOYEE M y0 ?rr5 Street Name city Zip Code HOME Or MAILING ADDRESS (If Different from Site Address) DATE: Date Service Completed (if already completed): , fYn aLki (Li Street Number Street Name CITY STATE CA ZIP PHONE #1 ExT• APN # Payment Date LAND USE APPLICATION # ( 209 ) 234-4341 Payment Type Yc�Invoice # Check # 111'9( PHONE#2 EXT. ( ) BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR Carl Wayne Henderson CHECK if BILLING ADDRESS® BUSINESS NAME Service Station Testing -SST INC / CSLB 962520 COMMENTS: Replaced MLLD at 91 STP. PHONE # EXT. ( 209 465-5577 HOME or MAILING ADDRESS PO Box 31465 FAX# ( 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: �/ �.,_ DATE: 6/26/14 PROPERTY / BUSINESS OWNER [3 OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT No President If APPLICANT is not the BILLING 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 at the same time it is provided to me or my representative. TYPE OF SERVICE REQUESTED:�� T PAYMENT RECEIVED COMMENTS: Replaced MLLD at 91 STP. MLLD tripped at 20 psi. JUN 26 2014 SAN JOAQUIN COUNTY ENVIROMENTAL HEALTH DEPARTMENT ACCEPTED BY: f EMPLOYEE M y0 ?rr5 DATE: Zd ASSIGNED TO: EMPLOYEE M DATE: Date Service Completed (if already completed): , fYn aLki (Li SERVICE CODE: � �8 PIE: 303 Fee Amount:`7s— Amount Paid Payment Date (0 3(o I cla Payment Type Yc�Invoice # Check # 111'9( Received By: ) � EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003