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r <br /> SAN JOAQUIN COUNTY ENVIRONMENTALAEALTH DEPARTMENT <br /> SERVICE REQUESTF P ? I 7017 <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Gas station, mini mart FAUO®-,W�i`PI€�O�y; °- �� I?l 77 <br /> OWNER/OPERATOR ,�� _.5, ; <br /> California Retail Management CHECK if BILLING ADDRESS❑ <br /> FACILITY NAME <br /> Chevron <br /> SITE ADDRESS <br /> 6633 Pacific Avenue Stockton T95207 <br /> Street Number Direction Street Name Cit Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) PO Box 1096 <br /> Street Number Street Name <br /> CITY STATE zip <br /> Carmichael /CA 95609 <br /> PHONE#1 �> Exr. APN# LAN USE APPLICATION# <br /> (916)488-3666 <br /> PHONE#2 ExT• BOS DISTRICT LOCATION CODE <br /> C TRACTOR/ SERVICE R�EQUESTOR <br /> REQUESTOR ' <br /> Greg Kaiser CHECK if BILLING ADDRESS❑ <br /> BUSINESS NAME PHONE# ExT. <br /> Kaiser Commercial Petrole 20 401-2379 <br /> HOME or MAILING ADDRESS j FAX# <br /> PO Box 1058 ( ) <br /> CITY Linden STATE CA Zip 95236 <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned perry or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific ENVIRONM L HEALTH DEPARTMENT hourly charges associated with this project or <br /> activity will be billed to me or my business as identified on is f Km. <br /> also certify that I have prepared this application and thnt the work,to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards, STATE and FE DE >L laws. <br /> APPLICANT'S SIGNATURE: DATE: 9/18/2017 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/ ANAGER ❑ OTHERAUTHORIZED AGENT Authorized Contractor <br /> If APPLICANT Is not the BILLING P TY proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMA ON: When applicable, I, the owner or operator of the property local t the above <br /> site address, hereby authorize the release f any and all results, geotechnical data and/or environmental/site asse dation <br /> t0 the SAN JOAQUIN COUNTY ENVIRONMENT HEALTH DEPARTMENT as Soon as it is aV ilable and at the same time it ifat <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: <br /> -19A A, �® <br /> COMMENTS: lvq1'4'&[/ROQU/N C <br /> Replace all (6) existing dispensers, change tank 3 unleaded to diesel, trench, insta I,piping from t .it <br /> (3) dispensers UDC's with Smith Fiberglass piping. RriyE4 <br /> ACCEPTED BY: EMPLOYEE#: I DATE: 7 j <br /> ASSIGNED TO: Aa-m r, EMPLOYEE#: DATE: �'�L , <br /> Date Service Completed (if already completed • N 7T SERVICE CODE: D P/E: 3 W <br /> Fee Amount: Amount Pai � L) Payment Date <br /> Payment Type Invoice# Check# 5-112- Rve ec By <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />