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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # SERVICE REQUEST # <br /> Fuel dispensing station 0000.4 � .- -- • <br /> OWNER / OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> Chevron Lathrop <br /> SITE ADDRESS Mossdale Lathrop <br /> 444 Street Number Direction Street Name Cil 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 # LAND USE APPLICATION # <br /> ( tog ) 234-2500 <br /> PHONE #2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR SERVICE REQIIESTOR <br /> REQUESTOR <br /> Emily Crain CHEC/< IfBILLING ADDRESS <br /> BUSINESS NAME PHONE # EXT. <br /> BZ Maintenance 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 same , <br /> acknowledge that all site and/or project eC is ENVIRONMENTAL HEALTH DEPARTMENT hourly Charges associated With this project Or <br /> activity will be billed to me or my busine s as I entified on this form . <br /> I also certify that I have prepared this p lic ton an t at the� ork be rformed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards, T E d F ER L I GAS . <br /> APPLICANT' S SIGNATURE DATE : <br /> PROPERTY / 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 above <br /> site address , hereby authorize the release of any and all results , geotechnical data and/or environmental/site assessment information <br /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the Same time it is prpyl*ed t0 me Or <br /> my representative. /�H Y <br /> TYPE OF SERVICE REQUESTED : <br /> COMMENTS : ,JUN <br /> Break concrete . Replace 87 and 91 spill buckets . Pour concrete . Test with county . sq 8 ZQZ© <br /> N <br /> NEgLIOgQ�UIT0 � <br /> COUNT <br /> ACCEPTED BY : l 1 ,� �iEMPLOYEE # : DATE : <br /> ASSIGNED TO : Q 2� C EMPLOYEE #: DATE : I/� I k "?o <br /> Date Service Completed ( if already completed) : SERVICE CODE : j PIE ::22t <br /> Fee Amount : �.J 0TI) Amount Pai ��� v � Payment Date 8 2D <br /> Payment Type �� Invoice # Check # c3 � s 3 � Recei ed By : <br /> EHD 48-02-025 SR FORM (Golden Rod) <br /> 07/17/08 <br />