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I Am SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH PEPPARTMENT SERVICE REQUEST ALv�'r �,. Type of Business or Property FACILITY ID # SERVICE REQUEST # GDF c? 0 . L1A 5 OWNER / OPERATOR Bob Lutz ExT. 465-5577 CHECK if BILLING ADDRESS FACILITY NAME Shell Food Mart FAX# ( 209 ) 465-4988 CITY Stockton STATE CA SITE ADDRESS 2320 N EI Dorado St I EMPLOYEE #: HEA R^ OAF"ritrk kA - Stokton 95209 Street Number Direction Street Name ----City-Zip Fee Amount: Code HOME or MAILING ADDRESS (If Different from Site Address) Payment Date 101 10 ) Payment Type Invoice # Check # 1 Street Number Received By: Street Name CITY STATE CA ZIP PHONE #1 ExT. APN # _ t ? LAND USE APPLICATION # ( 209 ) 943-1311 PHONE#2 ExT. BOS DISTRICTATION IF CODE CC, ( ) o1 CONTRACTOR / SERVICE REQUESTOR REQUESTOR Carl Wayne Henderson CHECK if BILLING ADDRESS BUSINESS NAMEPHONE# Service Station Testing -SST INC / CSLB 962520 PAYMENT 209 ExT. 465-5577 HOME or MAILING ADDRESS PO Box 31465 FAX# ( 209 ) 465-4988 CITY Stockton STATE CA ZIP 95213 BILLING ACKNOWLEDGEMENT: I, 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. 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, STATE and FEDERAL laws. APPLICANT'S SIGNATURE:cen--�`--- • DATE: 6/9/14 PROPERTY / BUSINESS OWNER 1:3 OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT la 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. TYPE OF SERVICE REQUESTED: COMMENTS: L-5: 87 annular 303 sensor intermittent sensor out alarm. PAYMENT Replaced 6-8-2014 and checked operation. RECEIVED JUN 10 2014 SAN JOAQUI`N COUNTY ACCEPTED BY: a c t EMPLOYEE #: HEA R^ OAF"ritrk kA - ASSIGNED TO: EMPLOYEE #: DATE: Date Service Completed (if already completed): 6/8/14 SERVICE CODE: P 1 E: , Fee Amount: Amount Paid Payment Date 101 10 ) Payment Type Invoice # Check # 1 Received By: EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003