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SAN JOAQUI,. . OUNTY ENVIRONMENTAL HEALTH .,e PARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property ^ FACILIrTY ID# /SERVICE REQUEST# <br /> GDF �'7 / (G1+7 S/1 DIS &'-? (G C(D <br /> OWNER/OPERATOR Vic Judge CHECK If BILLING ADDRESS <br /> FACILITY NAME ABC Food Mart-Valero Mr Cafe <br /> SITE ADDRESS 713 FN EI Dorado St Stockton 95202 <br /> Street Numberon 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 /> (X ) <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR Carl Wayne Henderson 16 1,5-C L CHECK If BILLING ADDRESS® <br /> BUSINESS NAME APEC PHONE# EXT. <br /> 209 943-3000 <br /> HOME or MAILING ADDRESS FAX# <br /> PO Box 55105 ( 209 ) 943-3003 <br /> CITY Stockton STATE CA ZIP 95205 <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 ENVIRONMI:NTAL HFAL.'rtl 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,STArL.:and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: ' _ DATE: 5-- Z <br /> PROPERT)'/13USINESSONNNER❑ OPERATOR/MANAGER ❑ OTHERAt'TIiORIZEDAGEN'r® Techninian <br /> f,APP/_tCANI is not the BILLING P,IaTI,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 ENVIRONENTAL 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: V J—F <br /> COMMENTS: Repairs/Adjustments per UST Inspectio Report dat 4/27/2011: MAY 2 5 2011 <br /> 17: Adjust Diesel hold pressure fo PLLD shutdown. SAN JOAQUIN COUNT) <br /> 18 &45: Replace gackets on fill sumps buckets for water tightness. (parts ordered) HEALTHENVIRONMENTAL <br /> DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: G DATE: <br /> ASSIGNED TO: �- EMPLOYEE#: L/ DATE: J <br /> Date Service Compl a (if already com ted) SERVICE CODE: f PIE: �3 O <br /> Fee Amount: Amount Paid 3 L(o. D 0 Payment Date S�a-S <br /> Payment Type Invoice# Check# 'Z, C Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br /> i <br />