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FlIkINE CPf JOAQUI*OUNTY ENVIRONMENTAL HEALTAPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> SERVICE STATION FODO�Oq q 5 F.00_)I O F <br /> OWNER/OPERATOR <br /> CHEVRON PRODUCTS COMPANY CHECK If BILLING ADDRESS❑ <br /> FACILITY NAME CHEVRON SS#208118 <br /> SITE ADDRESS 3355 EHAMMER LANE STOCKTON 95212 <br /> Street Number I Direction Street Name city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 30 MAIN AVE SUITE 5 <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> SACRAMENTO CA 95838 <br /> PHONE#1 ExT• APN# LAND USE APPLICATION# <br /> ( 925 ) 551.7555 <br /> PHONE#2 ExT• BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR MERLIN BOWEN(AGENT FOR CONTRACTOR-WAYNE PERRY) CHECK if BILLING ADDRESS <br /> BUSINESS NAME WAYNE PERRY,INC. PHONE# ExT• <br /> 925 551.7555 <br /> HOME or MAILING ADDRESS FAx# <br /> 30 MAIN AVE SUITE 5 ( 925 ) 646-9683 <br /> CITY SACRAMENTO STATE CA Zip 95838 <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 aanndFFEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: A/r-7Z7 7 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT W, Agent for Owner <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, I,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 safe time it is <br /> provided to me or my representative. '4y <br /> TYPE OF SERVICE REQUESTED: UPGRADE DISPENSERS with CONVERSION FRAMES *4 FAV T <br /> COMMENTS: '/p 9 <br /> INSTALL NEW DRESSER WAYNE DISPENSERS WITH CONVERSION FRAMES. ti Few ti°?Ofj <br /> RJM41 <br /> IO <br /> ACCEPTED BY: eI l t Vo e/1m( W O EMPLOYEE#: DATE: 3 (1 <br /> V G <br /> ASSIGNED TO: �v EMPLOYEE M DATE: 3 M/t-7 <br /> Date Service Completed (if already/lcompleted): SERVICE CODE: SC�qS PIE: Z�U$ <br /> Fee Amount: (� 1 Amount Pal /70 Payment Date �3Lq <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />