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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID # BUSINESS NAMEPHONE# Service Station Testing -SST INC / CSLB 962520 SERVICE REQUEST # GDF HOME or MAILING ADDRESS PO Box 31465 EMPLOYEE M FAX # ( 209 ) 465-4988 OWNER/ OPERATOR Jesse Diaz / Environmental Manager STATE CA ZIP 95213 CHECK if BILLING ADDRESS❑ FACILITY NAME Love's Country Store #223 Amount Paid Payment Date SITE ADDRESS 1553W Invoice # Colony Dr Received By: Ripon 95366 Street Number Direction Street Name city Zip Code HOME or MAILING ADDRESS (If Different from Site Address) Street Number Street Name CITY STATE CA PHONE #1 EXT. APN # LAND USE APPLICATION #'--" ( 405) 687-1060 PHONE#2 EXT. ( ) BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR Carl Wayne Henderson CHECK if BILLING ADDRESS® BUSINESS NAMEPHONE# Service Station Testing -SST INC / CSLB 962520 EMPLOYEE M EXT. 209 465-5577 HOME or MAILING ADDRESS PO Box 31465 EMPLOYEE M 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: y DATE: 8/12/14 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 provided to me or my representative. TYPE OF SERVICE REQUESTED: COMMENTS: REPAIRS PER ANNUAL MONITOR CERTIFICATION FINDINGS: MC PERFORMED 8-12-2014 Replace Diesel Fill Bucket (Nearest Store) Install 2 VMI 99-LD3000 MLLD's at both Diesel STP's (Replaces FePetro MLLD's) Replace 208 sensor at L40 under #15/16 (intermittent sensor out) ACCEPTED BY: EMPLOYEE M DATE: ASSIGNED TO: EMPLOYEE M DATE: Date Service Completed (if already Completed): SERVICE CODE: P I 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