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MLVL1 V L" FEB 2 5 2014 SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMEN ENVIRONMENTAL SERVICE REQUEST HEALTH DEPARTMENT Type of Business or Property FACILITY ID # SERVICE REQUEST # Commercial Fueling –1 .51Z 0912 9 OWNER / OPERATOR Valley Pacific Petroleum Services 2014 CHECK If BILLING ADDRESS Valley Pacific Petroleum Services Inc. FVEAd� D��IVT)' FACILITY NAME 166 Frank West Circle Valley Pacific Fresno Ave Cardlock ( 559 ) 732-0817 SITE ADDRESS STATE ZIP Stockton CA 95206 EMPLOYEE #: 1524Fresno Date Service Completed (if a eady completed): Ave SERVICE CODE: Stockton 95206 Street Number Direction Payment a e Street Name city Zip Code HOME or MAILING ADDRESS (If Different from Site Address) Cheek-# 0�9Z�.,F I Received By: Valley Pacific Petroleum 166 Frank West Circle Street Number Street Name CITY Stockton STATE CA ZIP 95206 PHONE #1 EXT. APN # LAND USE APPLICATION # (209 ) 993-8793 PHONE #2 EXT. ( ) BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR Mike Eliason CHECK if BILLING ADDRESS BUSINESS NAME FEB 2 s PHONE# ExT• Valley Pacific Petroleum Services 2014 209 1 993-8793 HOME or MAILING ADDRESS FVEAd� D��IVT)' FAX # 166 Frank West Circle 1if� ai' ( 559 ) 732-0817 CITY STATE ZIP Stockton CA 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 IiEALTH 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 I wS. APPLICANT'S SIGNATUREATE: PROPERTY/ BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTIIER AUTIIORI'ZED AGENT O Card lock Manager IfAPPLICA NT is not the BILLING PARTY, proof of authorization to sign is required Title AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, 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 environnlental/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: RE ENT COMMENTS: FEB 2 s 2014 FVEAd� D��IVT)' 1if� ai' ACCEPTED BY: EMPLOYEE #: DATE: ASSIGNED TO: ` EMPLOYEE #: DATE: Date Service Completed (if a eady completed): SERVICE CODE: P I E: 09, Fee Amount: – Amount Paid 37.5.00 Payment a e 2b 'f Payment Type 164— Invoice # Cheek-# 0�9Z�.,F I Received By: EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003