Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH IEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> GDF ATdIL 10 1242 <br /> OWNER/OPERATOR Dawn Cahill (405) 302-6685 7 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 <br /> 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: 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 /> 1 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: �--� ✓ DATE: 8/17/12 <br /> PROPERTY/BuSINESSOWNER❑ 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, 1,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 /> HEALTH DEPARTMENT <br /> ACCEPTED BY: I1 EMPLOYEE#: DATE: <br /> ASSIGNED TO: ►/ EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): g-11-I L— N ZC ONS SERVICE CODE: <br /> Fee Amount: Amount Paid 111��"7 S. Payment Date L V <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />