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SAN JOAQU1OUNTY ENVIRONMENTAL HEALTHOPARTMENT OPJGP& SERVICE REQUEST Type of Business or Property FACILITY ID # QUEST # SERVICE REQUEST GDF 1 7-7� ®'%U 3 q:a_ OWNER/ OPERATOR Wes Parker CHECK if BILLING ADDRESS FACILITY NAME Arco Hammer Lane STATE CA ZIP 95213 SITE ADDRESS 3250W RTM Hammer Lane I EMPLOYEE #: Stockton 95209 Street Number Direction Date Service Completed (if already com leted): Street Name City Zip Code HOME or MAILING ADDRESS (If Different from Site Address) Amount Pa' -743 Paym`e'nt Date Street Number Street Name CITY STATE CA ZIP PHONE #1 EXT.APN # LAND USE APPLICATION # ( 209 ) 474-9125 k--2- - 4 () _. PHONE #2 EXT. BOS DISTTRRIICCTT, LOCATION POPE CONTRACTOR / SERVICE REQUESTOR REQUESTOR Carl Wayne Henderson1 r '{OSI 7 � CHECK if BILLING ADDRESS BUSINESS NAME Service Station Testing -SST INC / CSLB 962520 COMMENTS: NOV Replace 4 Gilbarco Advantage dispensers 4 NEW Gilbarco Encore dispensers. 0 7 PHONE# EXT. 209 465-5577 HOME or MAILING ADDRESS PO Box 31465 -}- <a/�Q ' FAx# ( 209 ) 465-4988 CITY Stockton STATE CA ZIP 95213 BILLING ACKNOWLEDGEMENT: 1, 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 my business as identified on this form. 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 COUNTY Ordinance Codes, Standards, STATE and FEDERAL laws. APPLICANT'S SIGNATURE: (/� I-, � DATE: / b ' 2 9'^ 2 o i PROPERTY / BUSINESS OWNER OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT No President 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. QA Xg_ TYPE OF SERVICE REQUESTED: T— COMMENTS: NOV Replace 4 Gilbarco Advantage dispensers 4 NEW Gilbarco Encore dispensers. 0 7 existing with Including Bravo "Dispenser Conversion Frames" S ?Q AE'10A -}- <a/�Q ' I 1V cot H�TH/DE qE TA RTM ACCEPTED BY: EMPLOYEE #: DATE: o t T ASSIGNED TO: EMPLOYEE #: DATE: Date Service Completed (if already com leted): SERVICE CODE: (C7 P I E: v c, D Fee Amount: —_ Amount Pa' -743 Paym`e'nt Date Payment Type Invoice # Check # 1113 Received By: EHD 48-02-025 4s -bo —�U `� SR FORM (Golden Rod) REVISED 11/17/2003 V 'Ivry Nr