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10 <br />SAN JOAQU11'-; COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Properly <br />FACILITY ID # <br />CHECK If BILLING ADDRESS <br />SERVICE REQUEST # <br />GAS STATION <br />PHONE # <br />ExT <br />C �trJ' 9 �� <br />J <br />OWNER / OPERATOR <br />CHEVRON <br />CHECK if BILLING ADDRESS O <br />FACILITY NAME <br />FAx# <br />CHEVRON GAS <br />3181 LUYUNG DRIVE STE A <br />SITE ADDRESS <br />( 1 <br />916-636-9507 <br />CIMNCHO CORDOVA <br />STATE <br />ZIP95742 <br />10858 Street Number <br />Direction <br />TRINITY PR�KLName <br />STOCKTOI&I <br />9524.9Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />/ <br />Street Number <br />ASSIGNED TO: oej'fr , <br />Street Name <br />CITY <br />STATE ZIP <br />PHONE #1 ExT <br />APN # <br />LAND USE APPLICATION # <br />(209-)952 2213 <br />06602015 <br />Payment Date ( nl ( b <br />PHONE #2 ExT <br />( 1 <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />LUCY S ILVAS THOMAS <br />CHECK If BILLING ADDRESS <br />BUSINESS NAM <br />PHONE # <br />ExT <br />TOWN & CO TRY CONTRACTORS, INC <br />TYPE OF SERVICE REQUESTED: <br />916 636-9500 <br />HOME or MAILING ADDRESS <br />FAx# <br />3181 LUYUNG DRIVE STE A <br />COMMENTS: - <br />( 1 <br />916-636-9507 <br />CIMNCHO CORDOVA <br />STATE <br />ZIP95742 <br />BILLING ACKNOWLEDGEMENT: I, 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 1 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 alld FEDERAL laws. I r, 6 <br />APPLICANT'S SIGNAT DATE, �U/ <br />PROPERTY / BUSINESS OWNER❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT ® CONTRACTOR <br />If APPLICANT is not the BILLING PARTY proof of authorization to ,sign is required Tule <br />AUT_TI ORIZATION TO RELEASE INFQ1f%MATION: When applicable, 1, 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 />pioV1Ueu to nic or illy IG�[GJGIIt6U VG. <br />, d <br />TYPE OF SERVICE REQUESTED: <br />COMMENTS: - <br />FEB 1 9 )O a lo� <br />ENVIRONMENi EA , MSN M <br />PERMIT; SE <br />ACCEPTED BY'- ®---�'yJJ <br />EMPLOYEE #: <br />O�`� <br />DATE: • �� �a <br />/ <br />ASSIGNED TO: oej'fr , <br />EMPLOYEE #: <br />DATE: a as 1 O <br />Date Service Completed (if already completed): <br />SERVICE CODE: g <br />P t E: 01? <br />Fee Amount: 3 q,,5' <br />Amount Paid 3 l 6 _ <br />Payment Date ( nl ( b <br />Payment Type <br />Invoice # <br />Check # � Sb 3 <br />Received By: N7r.— <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />