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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID # SERVICE REQUEST # GDF S cI–I Sem f (P 15- 3�o OWNER/ OPERATOR CITY Stockton El ASSIGNED TO: T CHECK If BILLING ADDRESS FACILITY NAME Fast Lane DATE: Date Service Completed (if already completed): SITE ADDRESS 116 E Roth Rd P/ E: 23Q 9 Lathrop Amount Paid 7 95330 Street Number Direction Invoice # Street Name city Received By Zip 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 CHECK If BILLING ADDRESS® BUSINESS NAME Service Station Testing -SST INC COMMENTS: Replace auto diesel MLLD (failed durin PHONE # ExT' 209 465-5577 HOME or MAILING ADDRESS PO Box 31465 ACCEPTED BY: YVJ ti%tQ?/` 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: Cl� e_ , i' - DATE: 7/10/13 PROPERTY/ BUSINESS OWNER [3 OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT® 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 nrovided to me or my representative. TYPE OF SERVICE REQUESTED: 5 i �� COMMENTS: Replace auto diesel MLLD (failed durin annual monitor certification 7-9-2013) PA EniD RECEIVED JUL 1 1 2013 SAN JOAOUIN COUNTY ENVIR ACCEPTED BY: YVJ ti%tQ?/` EMPLOYEE #: --,7670 J A "r ASSIGNED TO: T EMPLOYEE #: 2� ri DATE: Date Service Completed (if already completed): SERVICE CODE: j g P/ E: 23Q 9 Fee Amount: 7�%s —� Amount Paid 7 Payment Date // t /3 _ Payment Type Invoice # Check # Received By EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003