Laserfiche WebLink
RE CITH EPAR <br /> AEA <br /> =CFW1VE0NTYENVIR0N -T <br /> Type of Business—or ftne'-r '. ' -lei? SERVICE REQUESTEP 2 0 2017 <br /> pbrty IJ I FACILITY ID III SERVICE REQUEST# <br /> Gas station, mini mart 'HE- '*Wl <br /> OWNERRQ"MENTAL:HEAER Ll SN �177 <br /> DEl"AHT M 73 <br /> DEPM11MEWail Management 1 CHECKII'SILLIN ADDRESS <br /> FAauTy NAME <br /> Chevron <br /> SITE ADDRESS <br /> (363 <br /> Pacific Avenue Stockton 95207 <br /> I., Folrar"On ZID Cc <br /> 4Z <br /> Street city <br /> How or MAILING ADDRESS (if Different from its <br /> Address) StreetNumbn PO Box 1096 <br /> CITY stmet Name <br /> Carmichael STATE CA zip 95609 <br /> PRONE 01 Exr. \APN# LAND USE APPLICATION# <br /> (916)488-3666 <br /> PHONE 02 EXT. SOS DISTRICT- LocAnom CODE <br /> CONTRAg�r /SERVICE REQUESTOR <br /> REQuEsToR <br /> Greg Kaiser CHECK If BILLING ADDRESS 13 <br /> BUSINESS NAME PHONE# <br /> Kaiser Commercial Petroleum (20 401-2379 <br /> HOME or MAwNG ADDRESS FAX# <br /> CITY PO Box 1058 <br /> Linden STATE CA zip 95236 <br /> BILLING ACK 1, the undersigned props business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific ENVIRONMENTHEAL? DEPARTMENT hourly charges associated with this project or <br /> IT <br /> activity will be billed to me or my business as Identified an this nn. <br /> I also certify that I have prepared this app on anq;althataw:work to be performed will be done in accordance With all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,S n 7- <br /> alwl <br /> APPLICANTS SIGNATURE: DATE: 9/18/2017 <br /> PROPERTY I BUSINESS OWNER[3 E R I ER 13 OTHER ALITH AGENT 13 'Authorized Contractor <br /> ff APPLICANT Is not proof of authorization to sign required Title <br /> L" <br /> AGENT <br /> gn rsqUil`4 <br /> I <br /> AUTHORIZATION TO REL FOR T N,Man applicable, 1, the owner or rator of the property locap t the above <br /> A�t; Ijg <br /> site address,hereby authorize he release any and all results,geotechnical data a environmental/site asse ation <br /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL EALTH DEPARTMENT as soon as it Is available at the same time it I.,. <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: <br /> Common: <br /> Replace all(6)existing dis <br /> change tank 3 unleaded to diesel,trench,install p%lpin fro�mt 0, **t <br /> laq <br /> (3)dispensers UDCs with 7mpigtherFiberglass piping. i 4 <br /> RA <br /> ACCEPTED BY: EmPLOYEE <br /> As&GNEDTO: DATE: <br /> EMPLOYEE DATE: • <br /> Date Service Completed (if already completed <br /> SERVICE CODE: jqq <br /> Fe*Amount4 LJq PIE: <br /> b Amount Pal oD Payment Date <br /> p.—Y..nt Type <br /> Invoice III Check# S-112-- Rec I By <br /> EHD 48-02-025 <br /> 07/17108 SR FORM(Golden Rod) <br />