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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID # SERVICE REQUEST # Fuel Station Cardlock N tJ J .5 `9 3 OWNER / OPERATOR Flyers Energy CHECK If BILLING ADDRESS FACILITY NAME Flyers Energy SITE ADDRESS Moffet Blvd Mateca 95336 983 Street Number Direction Street Name City Zin Code HOME or MAILING ADDRESS ( If Different from Site Address) East 4th Street 2500 Street Number Street Name CITY Sparks STATE NV ZIP 89512 PHONE #1 EXT, APN # LAND USE APPLICATION # ( 800 ) 899 -2376 PHONE #2 EXT, BOS DISTRICT LOCATION CODE ( ) CONTRACTOR / SERVICE REQUESTOR REQUESTOR Penn Tanner CHECK if BILLING ADDRESS ® BUSINESS NAME L . A. Perks Petroleum Specialist PHONE # EXT. ( 775 ) 358-4403 HOME or MAILING ADDRESS FAx 765 East Greg Street # 103 ( ) CITY Sparks STATE NV ZIP 89431 BILLING ACKNOWLEDGEMENT : I , 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 . 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 laws . APPLICANT' S SIGNATURE : o. I � DATE : 12-4- 18 PROPERTY / BUSINESS OWNER ❑ OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required Tt e 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 t0 me or my representative . TYPE OF SERVICE REQUESTED : Dispenser Swap An M / COMMENTS : N VZO F 0 5 2018 SAN 'JOAQUIN H eNVIRQNM COUNr�e ACCEPTED BY : tCN `n 0 m o EMPLOYEE # : DATE : , A' J ASSIGNED TO : ' t p ��J`� e r EMPLOYEE #: DATE: Date Service Comple -ted ( if already completed ) : SERVICE CODE : 1 Lf PI E : Fee Amount: Amount Paid C) U Payment \Date 12I S I g Payment Type S � Invoice # Check # f 5 �oZ � Received By : . EHD 48-02-025 SR FORM (Golden Rod ) 07/17/08