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SAN JOAQUWOUNTY ENVIRONMENTAL HEALTS, PARTMENT SERVICE REQUEST Type of Business or Property GDF FACILITY ID # Fo 00011 CHECK if BILLING ADDRESS® SERVICE REQUEST # -Ti\UC'5�v'vg OWNER/ OPERATOR Tom Graves (performed b others) on PAYMENT PHONE# EXT. 209 467-7573 CHECK if BILLING ADDRESS FACILITY NAME Shell - Lodi "PLAZA LIQUORS" FAx# ( 209 ) 465-4988 CITY Stockton SITEADDRESS 2420W Street Number Direction Turner Rd Street Name Lodi C ity 95242 Zip Code HOME or MAILING ADDRESS (If Different from Site Address) Street Number EMPLOYEE #: t 2- 42 DATE: Street Name CITY SERVICE CODE: STATE CA ZIP PHONE #1 EXT. ( ) APN # Payment Date C� LAND USE APPLICATION # PHONE #2 EXT. ( ) BOS DISTRICTLOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR Carl Wayne Henderson CHECK if BILLING ADDRESS® BUSINESS NAME HMC - Henderson Maintenance Company (performed b others) on PAYMENT PHONE# EXT. 209 467-7573 HOME or MAILING ADDRESS PO Box 31325 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: Com% +� - // DATE: PROPERTY/ BUSINESS OWNER OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT ® Contractor /f 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: TANK RETROFIT REPAIR COMMENTS: Sticking 91 STP relay discovered during ANNUAL MONITOR CERTIFICATION (performed b others) on PAYMENT 10/27/2009. RECEIVED OCT 2 8 2009 JOAQUIN COUNTY ACCEPTED BY: EMPLOYEE #:T EACH z7 G ASSIGNED TO: A � EMPLOYEE #: t 2- 42 DATE: Date Service Completed (if already comp) d): SERVICE CODE: P I E: 2 Fee Amount: Amount Paid -034s-. 1) Payment Date C� Payment Type ✓ Invoice # Check # f �� Received By: EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003