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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # SERVICE REQUEST # <br /> � K IU �- <br /> OWNER 1 OPERATOR <br /> Valley Pacific Petroleum Services CHECK If BILLING ADDRESS ❑ <br /> FACILITY NAME Valley Pacific Petroleum Cardlock - Charter Way <br /> SITE ADDRESS1501 W. Charter Way Stockton 95206 <br /> Street Number Direction Street Name city Zip Code <br /> HOME or MAILING ADDRESS ( If Different from Site Address) 152 Frank West Circle <br /> Street Number Street Name <br /> CITY Stockton STATE CA ZIP 95206 <br /> PHONE #1 EXT. APN # LAND USE APPLICATION # <br /> (209 ) 993 - 8793 �j1v l � <br /> PHONE #2 EXT. BOS DISTRICTS , LOCATION CODE <br /> 41 <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR Mike Eliason CHECKif13ILLINGADDRESS © <br /> BUSINESS NAME Valley Pacific Petroleum PHONE # EXT, <br /> 209 948 -9412 <br /> HOME or MAILING ADDRESS 152 Frank West Circle FAX # <br /> CITY Stockton STATE CA ZIP 95206 <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 or <br /> 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 : /�Z0 Ac) <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 , I , the owner or operator of the property locatedt the above <br /> site address , hereby authorize the release of any and all results , geotechnical data and/or environmental/site assess 46'r�to <br /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It IS available and at the Same time It IS pr <br /> my representative. / <br /> TYPE OF SERVICE REQUESTED : JAIAe <br /> COMMENTS : SAN <br /> ENVIRO U/N COSH ry <br /> HST H O pNPAL <br /> Aa <br /> ACCEPTED BY: q EMPLOYEE M � 6 7v DATE : ' �f <br /> ASSIGNED TO : l -kLj D EMPLOYEE M (J 3 DATE : <br /> Date Service Completed (if already completed) : SERVICE CODE : y PIE : Z30b' <br /> Fee Amount: �� _ Amount Pai qS6 ,, , v Payment Date 2 Z� <br /> Payment Type Invoice # Check # la3 91 3$ Received By : <br /> EHD 48-02-025 SR FORM (Golden Rod) <br /> 07/17/08 <br />