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SAN.TOAQUIN C OUNTY ENVIRONMENTAL HEALTHPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> GDF � � S 1�G(% � �✓ �7 <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITYNAME Valero-Manteca 'QUICK SHOP' <br /> SITE ADDRESS 1001 JE Yosemite Ave Manteca 95336 <br /> Street Number 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 /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <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 ) 465-4988 <br /> CIN Stockton STATE CA ZIP 95213 <br /> BILLING ACKNOWLEDGEMENT: I, 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 FEDE AL laws. <br /> APPLICANT'S SIGNATURE: C4--/ t,_ . DATE: 8/29/11 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT® President <br /> IfAPPLICANT APPL/CANT 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: TANK RETROFIT L'( 7- 08.C—T-X1-0 r t / AYMENT <br /> COMMENTS: Replace defective 208 sensor 8/29/2011. R <br /> AUG 3 0 2011 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: L i v F t EMPLOYEE#: Z� DATE: C) 3v f <br /> ASSIGNED TO: / EMPLOYEE#: DATE: 'y- <br /> Date <br /> Date Service Completed (if already completed): 8/29/11 SERVICE CODE: l` P I E: 3 Of <br /> Fee Amount: 7(�"' Amount Paid 3 7S- E)-D Payment Date 3d If I <br /> Payment Type Invoice# Check# 3 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />