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G 1 � <br />..� SERVICE REOUES' /',a 3 -----� r j.(EH 00 61) Revised 8/23/93 <br />�wv <br />FACILITY ID # 3 I��J RECORD ID #� INVOICE # <br />iC- 1171f <br />FACILITY NAME Cbevron U.S.A. BILLING PARTY Y / <br />SITE ADDRESS 3775 Tracy Blvd <br />CITY Trac)' CA ZIP <br />OWNER/OPERATOR Chevron U.S.A. Products Co. BILLING PARTY Y / <br />DBA PHONE #1 ( 510 ) 842 - 9002 <br />ADDRESS P.0 Box 5004 PHONE #2 ( ) - <br />CITY San Ramon STATE CA zip 94583 <br /># p Land Use Application # <br />21 Location Code <br />212-170-28 BOS Dist <br />CONTRACTOR and/or <br />SERVICE REOUESTOR Robert H. Lee & Associates BILLING PARTY (D / N <br />DBA <br />PHONE #1 ( 707 ) 765 - 1660 <br />MAILING ADDRESS 1137 N. McDowell FAX # ( 707 ) 765 - 9908 <br />I <br />CITY Petaluma STATE CA zip 94954 <br />BILLING ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknow Ledge that all site and/or project specific <br />PHS/EHD hourly charges associated with this facility or activity will be billed to the party iopgty"E(1� j[he BILLING PARTY on <br />Page 1 of this form. YRECEIVF n <br />I aLso certify that I have prepared this application and that the work to be performed will bj Utmlid} 4935ance with all SAN <br />JOAQUIN COUNTY Ordinance Codes and Standards, State and Federal laws. <br />///�/ /L /J � SHN JU/yTA�-GUiiv UC��NI r <br />APPLICANT'S SIGNATURE ///�r�"/�.Es� <br />Tit Le: veto 6'P//dr41 Date: //I/5' <br />AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, I, the owner, operator or agent of same, of <br />the property located at the above site address hereby authorize the release of any and alL results, geotechnical data and/or <br />environmental/site assessment information to SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as <br />it is available and at the same time it is provided to me or my representative. <br />Nature of Service Request-Y—i 1 Y7 rl) J/^''� ,6�y- 'A dgyy ice Code <br />Assigned to 4-� /ti f/ r L 4 Cd _ Employee # Date/2� <br />Date Service Completed / / Further Action Required: G / N PROGRAM ELEMENT 3 Ot-1 <br />Fee Amount Amount Paid <br />Date of Payment <br />Payment Type <br />Receipt # <br />Check # <br />Recvd By <br />REHS I /_Z / P'5 1 SUPV I _/ /_ I ACCT I _/_/ _ I UNIT CLK I _/_/, <br />