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SAN JOAQU*OUNTY ENVIRONMENTAL HEALTH aARTMENTI] ORIGINAL SERVICE REQUEST Type of Business or Property FACILITY ID # BUSINESS NAME Service Station Testing -SST INC / CSLB 962520 SERVICE REQUEST # GDF HOME or MAILING ADDRESS PO Box 31465 '6` OWNER/ OPERATOR Tulare Farms, LLLP CHECK if BILLING ADDRESS FACILITY NAME Tulare Farms Amount Paid SITE ADDRESS 2771 1 E French Camp Rd I Check # I Manteca 95336 Street Number Direction Street Name city Zip Code HOME or MAILING ADDRESS (If Different from Site Address) Street Number Street Name CITY STATE CA ZIP PHONE #1 EXT. APN # LAND USE APPLICATION # 1 209) 235-3055 PHONE #2 EXT. ( ) BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR Carl Wayne Henderson 505338 CHECK if BILLING ADDRESS® BUSINESS NAME Service Station Testing -SST INC / CSLB 962520 ASSIGNED TO: iewlm ji9LJ f) PHONE# EXT. 209 465-5577 HOME or MAILING ADDRESS PO Box 31465 Date Service Completed (if already completed): 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: C'--� L-- /-z--DATE: 1/26/15 PROPERTY / BUSINESS OWNER❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT ® President /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: Sr COMMENTS: Replace 420 sensor at T-1 with 344 micro sensor. 420 sensor COULD NOT be removed during annual testing. ANN*j L_Ar� 4;P4t,, % JAN- 2 7 101, 84'V J AQUIIV CO HEALTE'VH p�p EIV L. ACCEPTED BY: EMPLOYEE #: DATE: �7 ASSIGNED TO: iewlm ji9LJ f) EMPLOYEE M DATE: Date Service Completed (if already completed): SERVICE CODE: P ! E:� VVV Fee Amount:Vv Amount Paid Payment Date 1 J--% Payment Type Invoice # Check # I Received By: L EHD 48-02-025 REVISED 11/17/2003 SR FORM (Golden Rod)