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SAN JOAQUWOUNTY ENVIRONMENTAL HEALTPARTMENT SERVICE REQUEST Type of Business or Property GDF FACILITY ID # SERVICE REQUEST # S►2oo oorrg93 OWNER/ OPERATOR Michael Edgar CHECK if BILLING ADDRESS E] FACILITY NAME Tulare Farms, LLLP FAX # ( 209 ) 465-4988 SITEADDRESS 2771 Street Number E I Direction French Camp Rd Street Name Manteca city 95336 Zip Code HOME or MAILING ADDRESS (If Different from Site Address) Street Number 0hIN Street Name CITY STATE CA ZIP PHONE #1 EXT. APN # LAND USE APPLICATION # PHONE #2 EXT. ( ) BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR Carl Wayne Henderson 303520 CHECK if BILLING ADDRESS® BUSINESS NAME Service Station Testing -SST INC COMMENTS: Tankgard ATG: Replaced sensor wires to Zone 3 and repaired sensor connection at zone 2. Checked EG+ PHONE# EXT. 209 465-5577 HOME or MAILING ADDRESS PO Box 31465 EB 0 FSA 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'J DATE: 1/29/13 PROPERTY/ BUSINESS OWNER ❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT President If APPLICANT is not the B/LLING 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 A IQ COMMENTS: Tankgard ATG: Replaced sensor wires to Zone 3 and repaired sensor connection at zone 2. Checked EG+ operation multiple times. EB 0 FSA J HE t V/ 0hIN ACCEPTED BY: L-6CA.)EMPLOYEE #: o -;� DATE: 2 1113 ASSIGNED TO: A-1 EMPLOYEE #: G76 DATE: f 1 Date Service Completed (if already completed): 1/29/13 SERVICE CODE: / Di P 1 E: 23 OF Fee Amount: 3 7 .-- Amount Paid 3�0z) Payment Date l Payment Type Invoice # Check # / 2-D'2/y Received By: EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003 �ie T 2013 ►Tq�NTY TMFNT