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SAN JOAQUIY 1" OUNTY ENVIRONMENTAL HEALTH DEPARTMEN WGINAL <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID #SERVICE <br />BUSINESS NAME <br />Service Station Testing -SST INC / CSLB 962520 <br />COMMENTS: REPAIRS PER ANNUAL MONITOR CER IFICATION FINDINGS: <br />REQUEST # <br />GDF <br />0 I Z Lei <br />FAX # <br />( 209) 465-4988 <br />CITY Stockton <br />S90 (D -70.3 IC) <br />OWNER/ OPERATOR <br />FePetro MLLD's) <br />Replace 208 sensor at L40 under #15/16 (intermittent sensor out) <br />Jesse Diaz / Environmental Manager <br />SAN JOAQUIN COUNTY <br />CHECK if BILLING ADDRESS❑ <br />FACILITY NAME Love's Country Store #223 <br />ENVIROMENTAL <br />ACCEPTED BY: t1/1 "./I / r����1 EMPLOYEE M <br />j ' 7 <br />SITEADDRESS 1553W <br />ASSIGNED TO:J iVoTll/o' <br />Colony Dr <br />I <br />C�l/U�(} I <br />DATE: <br />Ripon <br />SERVICE CODE: <br />95366 <br />Street Number <br />Direction <br />Amount Paid <br />Street Name <br />Payment Date <br />3 114 <br />city <br />Zi Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />R ceived By:vV <br />Street Number <br />Street Name <br />CITY <br />STATE CA <br />ZIP <br />PHONE #'I EXT. <br />APN # <br />LAND USE APPLICATION # <br />( 405 ) 687-1060 <br />PHONE #2 EXT. <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR Carl Wayne Henderson <br />CHECK If BILLING ADDRESS In <br />BUSINESS NAME <br />Service Station Testing -SST INC / CSLB 962520 <br />COMMENTS: REPAIRS PER ANNUAL MONITOR CER IFICATION FINDINGS: <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: 1, 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 FEDERAL laws. <br />APPLICANT'S SIGNATURE: _�Z L.. �' DATE: 8/12/14 <br />PROPERTY / BUSINESS OWNER OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT to President <br />If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required 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. <br />TYPE OF SERVICE REQUESTED: (✓/ >T l--� ; <br />COMMENTS: REPAIRS PER ANNUAL MONITOR CER IFICATION FINDINGS: <br />PAYMENT— <br />MC PERFORMEMC ED <br />Replace Diesel Fill Bucket (Nearest Store) <br />AUG 1 3 X014 <br />Install 2 VMI 99-LD3000 MLLD's at both Diesel STP's (Replaces <br />FePetro MLLD's) <br />Replace 208 sensor at L40 under #15/16 (intermittent sensor out) <br />SAN JOAQUIN COUNTY <br />ENVIROMENTAL <br />ACCEPTED BY: t1/1 "./I / r����1 EMPLOYEE M <br />j ' 7 <br />DATE: 3 <br />ASSIGNED TO:J iVoTll/o' <br />EMPLOYEE <br />C�l/U�(} I <br />DATE: <br />Date Service Completed (if alrea y completed): <br />SERVICE CODE: <br />P 1 E: 2 Cog <br />Fee Amount: `;71� _�— <br />Amount Paid <br />Payment Date <br />3 114 <br />Payment Type <br />Invoice # <br />Check # <br />R ceived By:vV <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />