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SAN JOAQUI COUNTY ENVIRONMENTAL HEALTH EPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />GDF <br />FACILITY ID # <br />_� :�> <br />SERVICE REQUEST # <br />5C)C _7 Y L° <br />OWNER/ OPERATOR Van de Pol Enterprises <br />CHECK if BILLING ADDRESS ❑ <br />FACILITY NAME pacific Pride <br />DATE: <br />SITEADDRESS 351 <br />Street Number <br />1 N <br />Direction <br />Beckman Rd <br />Street Name <br />Lodi <br />City <br />95240 <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Street Number <br />Street Name <br />CITY <br />STATE CA ZIP <br />PHONE #1 EXT. <br />( ) <br />APN # <br />LAND USE APPLICATION # <br />PHONE #2 ExT. <br />BOS DISTRICTLOCATION <br />CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR Carl Wayne Henderson <br />2,039,07 CHECK if BILLING ADDRESS® <br />BUSINESS NAME Service Station Testing - SST INC <br />DATE: 7 / 13 <br />PHONE# EXT. <br />209 465-5577 <br />HOME or MAILING ADDRESS <br />PO Box 31465 <br />DATE: <br />FAx# <br />( 209 ) 465-4988 <br />CITY Stockton <br />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 />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 <br />COUNTY Ordinance Codes, Standards, STATE and FEDE L laws. <br />APPLICANT'S SIGNATURE: �' .--T/GDATE: 7/1/13 <br />PROPERTY/ BUSINESS OWNER OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT ® President <br />If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required Title <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, 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 A t is <br />provided to me or my representative. Ric.. /19 <br />TYPE OF SERVICE REQUESTED: M S� i -o <br />COMMENTS: Discovered during Annual Monitor Ce Ification (performed by others) - with Aris on site. qN Jo 1 <br />ti FN gO1J, <br />L-11 (Red Diesel Annular sensor) stuck at bottom in riser. Installed replacement 420 sensor at�'�V2jF Cp <br />POSSIBLE POSITION (on top of stuck sensor). Fp�R Tq <br />TM <br />ACCEPTED BY: <br />EMPLOYEE #: ;�b 7C) <br />DATE: 7 / 13 <br />ASSIGNED TO: C� <br />EMPLOYEE #: I q 2 Z <br />DATE: <br />Date Service Completed (if already completed): 6/28/13 <br />SERVICE CODE: l% 19 <br />P i E: Z36 <br />Fee Amount: 37.E <br />Amount Pa i 375, Da <br />Payment Date <br />1 3 <br />Payment Type <br />Invoice # <br />Check # 3�� <br />Received By <br />EHD 48-02-025 <br />REVISED 11/17/2003 <br />SR FORM (Golden Rod) <br />>3 <br />'Wry <br />T <br />