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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # ,SSERVICE REQUEST # <br /> Fuel dispensing station F1- 00 Coo 212 S I� T22 <br /> OWNE �QPERAT�. . V' n v' <br /> Ill/ CHECK if BILLING ADDRESS <br /> FACILITY NAME <br /> Chevron Lathrop <br /> SITE ADDRESS <br /> 444 Mossdale Lathrop <br /> Street Number Direction Street Name City Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE #1 EXT. APN # <br /> LAND USE APPLICATION # <br /> ( 209 1234-2500 <br /> PHONE #2 EXT, BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> Emily Crain CHECK if BILLING ADDRESS <br /> BUSINESS NAME BZ Maintenance PHONE # EXT, <br /> 916 371 -2380 <br /> HOME or MAILING ADDRESS FAX # <br /> PO Box 933 ( 916 371 -2540 <br /> CITY West Sacramento STATE CA Zip 95691 <br /> BILLING ACKNOWLEDGEMENT: I , the undersigned property or business owner, operator or authorized agent of Sar le , <br /> acknowledge that all site and/or project specic ENVIRONMENTAL HEALTH DEPARTMENT hourly Charges associated with this projec or <br /> activity will be billed to me or my busine s as identified on this form . <br /> I also certify that I have prepared this ap licabon and1hat the "work�t� be performed will be done in accordance with all SAN JOAQ JIN <br /> COUNTY Ordinance Codes, Standards , SrE lid F DERtj\L Ipws . <br /> APPLICANT'S SIGNATURE _ DATE ; <br /> PROPERTY I BUSINESS OWNER ❑ :/ OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT ® Project Manager <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 abi ve <br /> site address , hereby authorize the release of any and all results , geotechnical data and/or environmental/site assessment informs ii n <br /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is provided t0 m Or <br /> my representative . <br /> TYPE OF SERVICE REQUESTED : <br /> COMMENTS : <br /> Break concrete . Replace 87 and 91 spill buckets . Pour concrete . Test with county . <br /> ACCEPTED BY: EMPLOYEE #: DATE : <br /> ASSIGNED TO : EMPLOYEE M DATE : <br /> Date Service Completed (if already completed) : SERVICE CODE : PIE : <br /> Fee Amount: Amount Paid Payment Date <br /> Payment Type Invoice # Check # Received By : <br /> EHD 48-02-025 SR FORM (GoldenRod) <br /> 07/17/08 <br />