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SAN JOAQUI6OUNTY ENVIRONMENTAL HEALTVEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />-T <br />FACILITY ID # <br />SERVICE REQUEST # <br />Commercial Fueling <br />4 11 <br />—Y,k m &'7 /3 6'--' <br />OWNER /OPERATOR <br />N <br />Ty°� AR <br />Valley Pacific Petroleum Services Inc. <br />CHECK if BILLING ADDRESS <br />FACILITY NAME <br />MFNT <br />Valley Pacific Fresno Ave Cardlock <br />993-8793 <br />SITE ADDRESS <br />FAX # <br />DATE: s <br />I <br />166 Frank West Circle <br />1524 <br />I <br />Fresno Ave <br />I <br />STATE <br />Stockton <br />95206 <br />Street Number <br />Direction <br />37Sd� <br />Street Name <br />'ity <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Check # <br />Recei ed By: <br />Valley Pacific Petroleum <br />166 <br />F Frank West Circle <br />Street Number <br />Street Name <br />CITY Stockton <br />STATE CA ZIP 95206 <br />PHONE #1 EXT.APN <br /># <br />LAND USE APPLICATION # <br />(209 ) 993-8793 <br />PHONE #2 EXT. <br />( ) <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />+ AIIA1. <br />COMMENTS: <br />Mike Eliason <br />CHECK if BILLING ADDRESS ❑ <br />BUSINESS NAME <br />N <br />Ty°� AR <br />PHONE# <br />EXT. <br />Valley Pacific Petroleum Services <br />MFNT <br />209 <br />993-8793 <br />HOME or MAILING ADDRESS <br />FAX # <br />DATE: s <br />I <br />166 Frank West Circle <br />( 559) <br />732-0817 <br />CITY <br />STATE <br />Zip <br />Stockton <br />CA <br />95206 <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 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 FEDER laws. / <br />APPLICANT'S SIGNATURE:/ DATE: <br />PROPERTY/ BUSINESS OWNER❑ OPERATOR /MANAGER ❑ OTHER AUTHORIZED AGENT ® Cardlock Manager <br />Y APPLICANT is not the BILLING PARTY, proof of authorization to sign is required TW e <br />AUTHORIZATION TO RELEASE INFORMATION: 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&d at the same time it is <br />provided to me or my representative. 'qY <br />Agp <br />TYPE OF SERVICE REQUESTED: S IhaL <br />+ AIIA1. <br />COMMENTS: <br />VS',q 1 <br />?013 <br />hFq gQV�No <br />N <br />Ty°� AR <br />rq<N,Y <br />MFNT <br />ACCEPTED BY: --/ <br />EMPLOYEE #: <br />DATE: s <br />I <br />ASSIGNED TO: C <br />EMPLOYEE #: <br />DATE: <br />Date Service Completed (if already completed): <br />SERVICE CODE: \ <br />P/E: 2 J <br />Fee Amount: - Oo <br />Amount Pal <br />37Sd� <br />Payment Date <br />/6 <br />Payment Type t` <br />Invoice # <br />Check # <br />Recei ed By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />