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SAN .JOAQIOCOUNTY ENVIRONMENTAL HEALT*PARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />BUSINESS NAME <br />APEC <br />SERVICE REQUEST # <br />GDF <br />(p /g i <br />EMPLOYEE #: Q 3 Z f <br />`j`°..L?O <br />OWNER / OPERATOR <br />CHECK if BILLING ADDRESS❑ <br />Mr Angle <br />STATE CA ZIP 95205 <br />FAcIurYNAME Miramar Valero <br />P / E: ,y2 j & F <br />SITE ADDRESS 1 WS <br />Amount Paid <br />EI Dorado St <br />I <br />Payment Date <br />I 3 <br />Stockton <br />95206 <br />Street Number <br />Direction <br />Received By: <br />Street Name <br />City <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 />APN # <br />LAND USE APPLICATION # <br />( 209 ) 939-1906 <br />PHONE #2 EXT. <br />( ) <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR Carl Wayne Henderson <br />CHECK if BILLING ADDRESS® <br />BUSINESS NAME <br />APEC <br />COMMENTS: 12/02/2010: Replaced VMI 87 MLLD venting line pressure back to tank. DEC — 3 2010 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />PHONE # ExT. <br />209 943-3000 <br />HOME or MAILING ADDRESS <br />EMPLOYEE #: Q 3 Z f <br />FAX# <br />PO Box 55105 <br />( 209 ) 943-3003 <br />CITY Stockton <br />STATE CA ZIP 95205 <br />BILLING ACKNOWLEDGEMENT: 1, 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 FEDERAL laws. <br />APPLICANT'S SIGNATURE: ---, /'� DATE: / 2— q` / 0 <br />PROPERTY/BUSINESS OWNER 13 OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT® AUTHORIZED AGENT <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 time it is <br />provided to me. or my representative. <br />TYPE OF SERVICE REQUESTED: TANK RETROFIT <br />COMMENTS: 12/02/2010: Replaced VMI 87 MLLD venting line pressure back to tank. DEC — 3 2010 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />ACCEPTED BY: r� (it JEt <br />EMPLOYEE #: Q 3 Z f <br />DATE: Z Lt.� /t O <br />ASSIGNED TO: <br />EMPLOYEE #: 14,11 <br />DATE: (2 fo 3 /tc <br />Date Service Completed (if already completed): 12/2/10 <br />SERVICE CODE: / ! F <br />1 <br />P / E: ,y2 j & F <br />Fee Amount: 3(�6.0O <br />Amount Paid <br />J&'(0_ ee <br />Payment Date <br />I 3 <br />Payment Type <br />Invoice # <br />Check # 1 (' <br />Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />