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SAN JOAQUIN %-;OUNTY ENVIRONMENTAL HEALTH L EPARTMENT ORIGINAL <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> GDF 3732 (Za07L 97,•' <br /> OWNER/OPERATOR Balaji Angle CHECK if BILLING ADDRESS <br /> FACILITY NAME 99 Shell <br /> SITEADDRESS 7700 Moreland Ct Stockton 95212 <br /> Street Number Direction 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 Exr. APN# LAND USE APPLICATION# <br /> ( 209 ) 957-5398 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / 01 <br /> REQUESTOR Carl Wayne Henderson 50,5-60(dCHECK if BILLING ADDRESS <br /> BUSINESS NAME Service Station Testing - SST INC/CSLB 962520 PHONE# EXT. <br /> 209 465-5577 <br /> HOME or MAILING ADDRESS FAx# <br /> PO Box 31465 (209 ► 465-4988 <br /> CITY Stockton STATE CA ZIP 95213 <br /> BILLING ACKNOWLEDGEMENT: thorized agent of same, <br /> acknowledge that all site and/or projec ssociated with this project <br /> or activity will be billed to me or my b SEE ATTACHED <br /> 1 also certify that 1 have prepared this a S R0072975 ince with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, <br /> APPLICANT'S SIGNATURE: dated 8-26-15 <br /> PROPERTY/BUSINESS OWN ER❑ OPERATOR/MANAGER U OTHER AUTHORIZED AGENT <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 t0 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: UST RETROFIT SR0072975 <br /> COMMENTS: AUG 2 7 2015 <br /> SR0072975 (Fee paid 8-26-2015 ) SEE ATTACHED SR dated 8-26-15 <br /> ENVIRONMENTAL HEALTH <br /> Replace 304 sensor at#1/2 UDC annular PERMIT(SERVICES <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P I E: <br /> Fee Amount: Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />