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SAN JOAQUIWOUNTY ENVIRONMENTAL HEALTIMEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID # SERVICE REQUEST # FAdc)o3 ao 6n$72L OWNER / OPERATOR CHECK If BILLING ADDRESS Ne l l a Oil Company, LLC DATE: FACILITY NAME Ne l l a - Olympian #427 SITE ADDRESS 3300 I Waterloo Road Stockton 95205 Street Number Direction Check # 3 ^a Street Name city Zip Code HOME or MAILING ADDRESS (If Different from Site Address) 2360 Lindbergh Street Street Number Street Name CITY Auburn STATE CA ZIP 95602 PHONE #1 ExT• APN # LAND USE APPLICATION # (530)885-0401 ext. 2301 PHONE #2 Exr. ( ) BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR Walton Engineering, Inc. CHECK if BILLING ADDRESS El BUSINESS NAME PHONE # ExT.( `� Walton Engineering, Inc. (��,.`.�._IVFf. 916 3 7 3 -116 5 HOME or MAILING ADDRESS F P.O. Box 1025 a)v222010 ( FAx 373-1173 ) CITY West Sacramento _ STATE CA ZIP 95691 BILLING ACKNOWLEDGEMENT: I, the undersigned pr-'#' ner, operator or authorized agent of same, acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH EPA ENT hourly charges associated with this project or activity will be billed to me or my business as identified on this form. 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, ST E a 77F��EDERAL laws. gg APPLICANT'S SIGNATURE: �I(1 tom—' DATE: PROPERTY / BUSINESS OWNER OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT ❑ IfAPPLICANT 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. TYPE OF SERVICE REQUESTED: Minor Repair - Replace Diesel Spill Bucket & Annular Sensor COMMENTS: Sawcut remove & dispose of concrete adjacent to failed spill containe Excavate to expose, remove & dispose of spill bucket & install replacement OPW 2100 Series series spill container, Obtain Inspection prior to backfill Backfill, and restore concrete suing 44 rebar as required. Replace three UST annular sensors and perform post construction final certification. ACCEPTED BY: EMPLOYEE #: G G DATE: 3 ASSIGNED TO: Z�-L EMPLOYEE #: DATE: Date Service Complet if already comp) : SERVICE CODE: ` P I E: 2308 Fee Amount: C+ 41 Amount Paid Payment Date v Payment Type Invoice # Check # 3 ^a Receive By: EHD 48-02-025 /' (� SR FORM (Golden Rod) REVISED 11/17/2003 \ , 1