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SAN JOAQUII,, COUNTY ENVIRONMENTAL HEALTH i,EPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> GDF fj2jmk/� O 6 v <br /> OWNER/OPERATOR Dawn Cahill (405) 302-6685 i CHECK if BILLING ADDRESS❑ <br /> FACILITY NAME Love's Travel Stops& Country Stores <br /> SITE ADDRESS 1553 W Colony Rd Ripon 95366 <br /> Street Number I Direction I Street Name city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE CA ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> ( 209 ) 599-0740 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR Carl Wayne Henderson CHECK if BILLING ADDRESS® <br /> BUSINESS NAME PHONE#_ ExT. <br /> Service Station Testing-SST INC 209 465-5577 <br /> HOME Or MAILING ADDRESS FAx# <br /> PO Box 31465 (209 1 465-4988 <br /> CITY Stockton STATE CA ZIP 95213 <br /> BILLING ACKNOWLEDGEMENT: I, 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: ClDATE: 8/17/12 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT® 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: PAYMENT <br /> COMMENTS: Replaced 420 sensor at 91 annular on 8/17/12. <br /> Will diagnose and repair diesel#1 &20k Unleaded spill buckets as needed. AUG 2 1 2012 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HATH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): 8-11'1 Z^ L4 Zo OtV,_ SERVICE CODE: P i E: <br /> Fee Amount: ­15 1 SC <br /> Amount Paid 37 S-. O Payment Date Z. <br /> Payment Type Invoice# Check � Received By: �. <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />