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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID # SERVICE REQUEST # COMMERCIAL YARD A 000310 L 261) OWNER / OPERATOR CHECK If BILLING ADDRESS DART CONTAINER CORPORATION FACILITY NAME DART CONTAINER CORPORATION SITE ADDRESS 1400 E VICTOR ROAD LODI 95240 Street Number Direction I Street Name City Zip Code HOME or MAILING ADDRESS ( if Different from Site Address ) 6805 SIERRA COURT, SUITE G Street Number Street Name CITY STATE ZIP DUBLIN CA 94568 PHONE #1 EXT. APN # LAND USE APPLICATION # ( 925 ) 551 .7555 PHONE #2 EXT. BOS DISTRICT7LOCATION CODE ( ) CONTRACTOR / SERVICE REQUESTOR REQUESTOR MERLIN BOWEN CHECK if BILLING ADDRESS BUSINESS NAMEPHONE # ExT. Gettler Ryan Inc . 925 551 .7555 HOME or MAILING ADDRESS FAX # 6805 SIERRA COURT, SUITE G ( 925 ) 551 -7888 CITY DUBLIN STATE CA ZIP 94568 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 FED la /} C� APPLICANT 'S SIGNATURE : DATE : PROPERTY / BUSINESS OWNER ❑ OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT Agent for Owner If 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 locat the above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site a e�w information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the samu�Fllsis' �� provided to me or my representative . TYPE OF SERVICE REQUESTED : SPILL BUCKET / OVERFILL VALVE INSTALLATION 4qAj ? J f COMMENTS : y�qFVUU ��ROQV�NC O�J REMOVE EXISTING SPILL BUCKET ON DIESEL UST AND INSTALL NEW OPW SPILL BUCKET WITH OPW-71SO OVERFILL ` rly� NMRF O N PROTECTION VALVE , REMOVE EXISTING BALL-FLOAT IF EXISTING . ACCEPTED BY : IL ! , EMPLOYEE #: <7 " I DATE : a lin-^ C� ASSIGNED TO : V EMPLOYEE # : DATE : Date Service Completed ( if already completed ) : SERVICE CODE: P I E: 0( Fee Fee Amount: Amount Pai 5 /0. D� Payment Date 7 Payment Type Invoice # Check # Rece ved By : EHD 48-02-025 SR FORM (Golden Rod) REVISED 11 /17/2003