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SAN JOAQU -'OUNTY ENVIRONMENTAL HEALTi EPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID # SERVICE REQUEST # Commercial Fueling (Cardlock) � C� 1 ( !�;;�co 1 OWNER/ OPERATOR PHONE# 209 EXT. 993-8793 Valley Pacific Petroleum Services, Inc. CHECK if BILLING ADDRESS❑ FACILITY NAME CITY Stockton STATE CA Valley Pacific Fresno Ave Cardlock EMPLOYEE M SITE ADDRESS 1524 Date Service Completed (if already completed): Fresno Ave I SERVICE CODE: yt) Stockton 95206 Street Number Direction Payment Type %J kInvoice Street Name Check # city Zip Code HOME or MAILING ADDRESS (if Different from Site Address) ] Frank West Circle Street Number Street Name CITY Stockton STATE ZIP 95206 PHONE #1 EXT. AP #15 LAND USE APPLICATION # (209 ) 948-9412 t(o33 7�a PHONE #2 EXT. BOS DISTRICT LOCATION CODE ( ) 993-8793 11 CONTRACTOR / SERVICE REQUESTOR REQUESTOR Mike Eliason CHECK If BILLING ADDRESS BUSINESS NAME Valley Pacific Petroleum Services, Inc. JUN 12 20115 PHONE# 209 EXT. 993-8793 HOME or MAILING ADDRESS 152 Frank West Circle ENVIROMENTAL FAX# ( 209) 948-0755 CITY Stockton STATE CA Zip 95206 BILLING ACKNOWLEDGEMENT: 1, 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 FFDF.RAI. laws. APPLICANT'S SIGNATURE: / DATE: 6/11/2015 PROPERTY/ BUSINESS OWNER [3 OPERATOR/ MANAGER ® OTHER AUTHORIZED AGENT ❑ 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 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 RE UST :�" COMMENTS' RECEIVED JUN 12 20115 SAN JOAQUIN COUNTY ENVIROMENTAL ACCEPTED BY: EMPLOYEE #: DATE: ASSIGNED TO: EMPLOYEE M DATE: % I Date Service Completed (if already completed): SERVICE CODE: yt) P I E: Z� Fee Amount: ,4 3%1C .Co Amount Paid 3 (9. Payment Date 6 a Payment Type %J kInvoice # Check # Received By:i"Gv EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003