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E Qg:11VE-0 <br /> A QUIN COUNTY ENVIROWE"',`70ta 01LEA&TH bgO <br /> SERVICE REQUES, �-p 2 0 2017 <br /> Type of Business or Prop" t4-f AL HE ALT H, <br /> I M��rj\J-f-'AJ L1,1L -k -1 P77 <br /> Gas sqtkv ffib"w "FAauTy E119�IR,0 N & )0 ID# SERVICE REQUEST <br /> OWNERIOP&ATOR 77M.1,1- <br /> Callifornia Retail Management CHECK If SILUNrp AoDRE-SS <br /> CI <br /> FACILITY NAME <br /> Chevron <br /> SITE ADDRESS <br /> 6633 Pacific Avenue Stockton 95207 <br /> tNumber D13 tI- StreatNa cttv I <br /> -- -- ZIOCC40 <br /> HOME or MAILING ADDRESS (it Different l—M Site Address) PO Box 1096 <br /> het Number <br /> CITY I <br /> Carmichael STATE CA ZIP 95609 <br /> PHDK#1 Exr. r# LAND USE APPLICATION III <br /> (916)488-3666 cu <br /> . SOS. — <br /> ( N SOS DISTRICT LOCATION Cow <br /> CONTRAR i SERVICE REQU)ESTOR <br /> REOUESTOR <br /> Greg Kaiser CHECK If BILLING AooRrs 13 <br /> BUSINESS NAMEKaiser Commercial Petroleum TP—liONE# Ev. <br /> 1 (2091 401-2379 ► <br /> HOME or MAILING ADDRESS FAX# <br /> PO Box 1068 1 <br /> CITY Linden V STATE CA ZIP 95236 <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned prop business owner, operator or authorized agent of some, <br /> acknowledge that all site and/or project specific ENVIRONMENT H DEPARTMENT hourly charges associated with this project or <br /> activity WIN be billed to me or my business as identified on th rm. <br /> I also certify that I have prepared this app on tha 9 work to performed Will be done in accordance With all SAN JOAQUIN <br /> COUNTY Ordinance Codes,StandardS,STAT F laws. <br /> APPLICANT'S SIGNATURE: DATE: 9118/2017 <br /> PROPERTY I BUSINESS OWNER 13 R1 ER El OTHER IZEDAGENT CS Authorized Contractor <br /> ff AppucAw Is not t etc tl proof of authorization to Is required - Title <br /> AUTHORIZATION TO REL 1 F When applicable, 1, the ow or operator of the property locao above <br /> WVV� the I <br /> site address,hereby authorize the release any and all results,geotechnical and/or environmental/aft as ation <br /> to the SAN JOAQUIN COUNTY ENVIRONMENT HEALTH DEPARTMENT as soon as <br /> my representative. It IS ava Is and at the same time it It <br /> ?r <br /> TYPE OF SERVICE REQUESTED: <br /> *A A, *I- <br /> Vo <br /> 4Q, <br /> Replace all(6)existing di,--�e <br /> change tank 3 unleaded to diesel,trench,in trench, piping from QP1 t <br /> (3)dispensers UDCs with Smith Fiberglass piping. <br /> AccEPTEo BY: PJ AA 11A �t' EMPLOYEE <br /> DATE: <br /> ASSIGNED To: EMPLOYEE 6( <br /> -Aalln-(A- DATE. q. <br /> Data Service Completed (if already complated)o SERVICECOU: 4q q, p1F. <br /> FeaAmount- Amount Pal3�4� <br /> (0— ate <br /> Check# <br /> Payment Type — <br /> Invoice Received By. <br /> EHD 48-02-025 <br /> 07117108 SR FORM(Golden Rod) <br />