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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID # SERVICE REQUEST # UG OWNER f OPERATOR CHECK If BILLING ADDRESS ❑ Pacific Gas & Electric FACILITY NAME pacific Gas & Electric, Stockton Service Center SITE ADDRESS 4040 West Lane Stockton95204 Street Number Direction Street Name Cit Zip Code HOME or MAILING ADDRESS (If Different from Site Address) Street Number Street Name CITY STATE Zip PHONE #1 EXT. APN # LAND USE APPLICATION # ( ) [PHONE #Z EXT. BOS DISTRICT LOCATION CODE ( ) CONTRACTOR / SERVICE REQUESTOR REQUESTOR Kristin Reynolds CHECK if BILLING ADDRESS ® BUSINESS NAME TAIT Environmental Services PHONE # EXT* 224 - 7280 HOME or MAILING ADDRESS 11280 Trade Center Drive FAx # CITY Rancho Cordova STATE CA ZIP 95742 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 m business as identified on this form . act Y Y 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 , S and FEDERAL laws . APPLICANT' S SIGNATURE : DATE : PROPERTY / BUSINESS OWNER ❑ OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT n Contractor 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 . Saw cut and remove existing waste oils ill bucket / Install new OPW Edge 1 ) 5 TYPE OF SERVICE REQUESTED : gallon spill bucket and straight drop tube . PA)qoe IV COMMENTS : Ce � � w AUG 22 S9(� AN JOA HNVjROtiMcNOU 1Y ACCEPTED BY : EMPLOYEE # : /(� DATE : �� / ME T ASSIGNED TO : EMPLOYEE # : I Z DATE : Date Service Completed ` ( if already completed ) : SERVICE CODE : PIE : Fee Amount . C� �'�' Amount PaidO. � 0 Payment Date S� Payment Type Invoice # Check # 5y(2 Rec ived By : EHD 48-02-025 SR FORM (Golden Rod) 07/ 17/08