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SAN J OAQUTy r AUNTY ENVIRONMENTAL HEALTH P7PARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID # BUSINESS NAME Service Station Testing - SST INC / CSLB 962520 SERVICE REQUEST # GDF HOME or MAILING ADDRESS EMPLOYEE M FAX# OWNER / OPERATOR SERVICE CODE: CHECK if BILLING ADDRESS ❑ FACILITY NAME Fast Lane STATE CA ZIP 95213 Payment Date SITE ADDRESS, 116 E Lathrop Rd Lathrop 95330 Street Number D ort. treet Name city ZipCode HOME or MAILING ADDRESS (If Different from Site Address) Street Number Street Nam CITY STATE CA ZIP PHOME Exr. e ApN # LAND USE APPLICATION # ( 209 ) 234-4341 PHONE #2 EXT. ( ) SOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REOUESTOR REQUEST& Carl Wayne Henderson CHECK if BILLING ADDRESSEXT® BUSINESS NAME Service Station Testing - SST INC / CSLB 962520 EMPLOYEE #: PHONE#' 209 465-5577 HOME or MAILING ADDRESS EMPLOYEE M FAX# PO Sox 31465 SERVICE CODE: ( 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: �L ,t ,�✓__ DATE: 11/13113 z PROPERTY / BUSINESS OWNER❑ 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 nrnvitiPA to me. or my representative. TYPE OF SERVICE REQUESTED: COMMENTS: ATG COLDSTART (GASOLINE SIDE): H-8 Comm alarm (Dead Battery) Replaced Battery, restored from archive and checked operation. } ACCEPTED BY: EMPLOYEE #: DATE: ASSIGNED TO: EMPLOYEE M DATE: Date Service Completed (if already completed): 11/12/13 SERVICE CODE: P1 E: Fee Amount: Amount Paid Payment Date Payment Type Invoice # Check # Received By: EHD 48-02-025 SR FORM (Golden Rod) , REVISED 11/17/2003