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SAN JOAQU*OUNTY ENVIRONMENTAL HEALTH WARTMENT SERVICE REQUEST 0PJG1X Type of Business or Property FACILITY ID # BUSINESS NAME Service Station Testing -SST INC / CSLB 962520 SERVICE REQUEST # GDF l t7J 0 b 4A1- 51Z b G� OWNER / OPERATOR Bob Lutz STATE CA ZIP 95213 CHECK if BILLING ADDRESS FACILITY NAME Shell Food Mart SAN JOAQUIN COUNTY ACCEPTED BY: ` CrlT SITE ADDRESS 2320 N I EI Dorado St I Stokton DATE: Date Service Completed (if already completed): 6/8/14 95209 Street Number Direction Fee Amount: -tJ�ij Street Name citv Payment Date Io t tJ Payment Type e ,(� Zip Code HOME or MAILING ADDRESS (If Different from Site Address) Check # j 11 Received By:a� Street Number Street Name CITY STATE CA Zip PHONE #1 ExT• 209 943-1311 APN #LAND t Z � _ Z` D'3� 0 USE APPLICATION # ( ) PHONE #2 ExT• BOS DISTRICTCATION CODE ( ) cL 7LO C'1 CONTRACTOR / SERVICE REQUESTOR REQUESTOR Carl Wayne Henderson CHECK if BILLING ADDRESS® BUSINESS NAME Service Station Testing -SST INC / CSLB 962520 COMMENTS: L-5: 87 annular 303 sensor intermittent sensor out alarm. PHONE# EXT. 209 465-5577 HOME or MAILING ADDRESS PO Box 31465 FAx# ( 209 ) 465-4988 Clrr 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: C--� DATE: 6/9/14 PROPERTY / BUSINESS OWNER ❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT ® 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. DECEIVED JUN 10 2014 SAN JOAQUIN COUNTY ACCEPTED BY: ` CrlT EMPLOYEE #: HEA WULPA 9 l ' ASSIGNED TO: , / �\ EMPLOYEE #: DATE: Date Service Completed (if already completed): 6/8/14 SERVICE CODE: P 1 E: Z3 Fee Amount: -tJ�ij Amount Paid Payment Date Io t tJ Payment Type e ,(� Invoice # Check # j 11 Received By:a� EHD 48-02-025 REVISED 11/17/2003 SR FORM (Golden Rod)