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i 0 SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of business or Property —FfAQLv58aL1 FACILITY ID d SERVICE REQUEST d GAS STATION/MINI MART GREG KAISER OWNER / OPERATOR BustNeas NAME AssioNso% _ M A �5 7*fr CHECK if au uN0 ADDRESS Fncntrr NAME KAISER COMMERCIAL PETROLEUM CHEVRON HOME or MAILING ADDRESS Amount Pald SITE ADDRESS FAX A Payment Type -Ir PO BOX 1058 Check # S-;LS—1 6633 LINDEN PACIFIC AVENUE STOCKTON 95207 Wrost Number• HOME Of MAILING ADDRESS (if Different from Site Address) PO BOX 1058 strostNumr b•StaotNams CITY STATE ZIP CARMICHAEL CA 95009 PHONE NI aM APN A LAND UsE APPucm= # (916)488.3666 PHONE N2 BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REOUESTOR REQUBSTOR COMMENTS: ry1;,�M�jiiPAW�)IJN To break out existing fill maiwrays (Fiber Lite) and Install Phil -rite 42" multiport manways so All bucket will holliitAlgt 5 gallons on all three tanks. 'y&NT AcCEPTED BY. e,m-- Magi Ain1 GREG KAISER EMPLOYR'ES: BustNeas NAME AssioNso% PHONE 11 M. DATE; KAISER COMMERCIAL PETROLEUM 208 401-2379 HOME or MAILING ADDRESS Amount Pald '`S6. OD FAX A Payment Type -Ir PO BOX 1058 Check # S-;LS—1 CITY LINDEN STATE CA ZIP 95236 BILLING ACKNOWLEDGEMENT, I, the undersigned property or business owner, operator or authorized agent of some, acknowledge that all alto and/or project spedtlo ENviRoNmEuTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as Identified on this form. 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 COUNTY Or+dInane Codes, Standards, S a FEDERAL laws. APPLICANT'S SIGNATURE: DATE.- 02/08/2018 PROPERTY I BUsINESa OWNER ❑ RATOR I MANAGER ❑ OTHER AUTHoluzan A©ENT ® AUTHORIZED CONTRACTOR /fAPPLicANrIs not t proof of authorization to sign is required Tills AUTHORIZATION TO S : When applicable, i, the owner or operator of the property loco rf(QI a site address, hereby authorize the release of any and all results, geotechnloal data and/or enAronmentevalte assess ofQ " I to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 88 soon as it Is available and at the some time it Is prov drtba my representative. r,»,Ob. TYPE OF SERVICE REQUESTED: COMMENTS: ry1;,�M�jiiPAW�)IJN To break out existing fill maiwrays (Fiber Lite) and Install Phil -rite 42" multiport manways so All bucket will holliitAlgt 5 gallons on all three tanks. 'y&NT AcCEPTED BY. e,m-- Magi Ain1 EMPLOYR'ES: DATE: 1 AssioNso% BMPLOveaIY; DATE; Date Service Completed (if already completed): I SER U CODE: PIE; Fee Amount: Amount Pald '`S6. OD Payment Date Payment Type -Ir Invoice # Check # S-;LS—1 Received By: EHD 48-02-026 SR FORM (Golden Rod) 07/17/08