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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTm DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Convenience Store ��' , i q 4 -7 <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS❑ <br /> Chevron <br /> FACILITY NAME <br /> Chevron Extra Mile <br /> SITE ADDRESS <br /> 3355 Hammer Lane Stockton 95219 <br /> Street Number Direction Street Name it Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) mber St <br /> 6001 Bollinger Canyon Rd Street Nureet Name <br /> CITY STATE ZIP <br /> San Ramon CA 94583 <br /> PHONE#'I EXT. APN# LAND USE APPLICATION# <br /> ( 925 )842-0868 1-2 G I X0 — C 1 <br /> PHONE#T EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> David Bartels CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> StariteC Architecture Inc. <br /> 707 774-8338 <br /> HOME or MAILING ADDRESS FAX# <br /> 1383 N. McDowell Blvd, Suite 250 ( 707 )765-9908 <br /> CITY Petaluma STATE CA ZIP 94954 <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 FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required Title <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 and at the same t"e,lX is <br /> provided to me or my representative. .. <br /> 'Ir <br /> TYPE OF SERVICE REQUESTED: plan Check " /`'Z 0 / RFC , <br /> COMMENTS: `C <br /> �.b,�� X 2414 ENVIRONMENTAL HEALTH <br /> "EaENQ. u,,ry PERMIT/SERVICES <br /> ACCEPTED BY: A�, ��1)i1— EMPLOYEE M DATE: (Y1, /-7 <br /> ASSIGNED TO: L 1 C EMPLOYEE#: DATE: <br /> Date Service Completed (if already con�eted): SERVICE CODE: !T Z 3 P/E: b O I <br /> Fee Amount: $390 1 Amount Paid $390 1 Payment Date $390 —H <br /> Payment Type Invoice# Check# //070 Received By:W <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />