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SAN.JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> t <br /> Type of Business or Property FACILITY ID ii SERVICE REQUEST A <br /> GAS STATION/MINI MART 5 t <br /> OWNER d OPERATOR L <br /> 0w lqot> <br /> #FAcMiuTYNAMEll,CHEVRON <br /> 6633 PACIFIC AVENUE STOCKTON 95207 <br /> t *Raw <br /> HOME Or MAILING ADDRESS (if Different from site Address) PO BOX 1096 <br /> Street Number <br /> CITY STATE ZIP <br /> CARMICHAEL CA 95609 <br /> PHONE Ni exit APN of LAND Use APrucATtot 0 <br /> (916)488-3666 <br /> PHOK I€2 Ea. SOS DismcT LOCATION CODE <br /> { ) <br /> CONTRACTOR/SERVICE RE+QUESTO <br /> Rr=_QUESTor: <br /> GREG KAISER <br /> Busmas NAME PHONE# <br /> KAISER COMMERCIAL PETROLEUM 209 401-2379 <br /> HOME or MAwNe ADDRESS FAX If <br /> PO BOX 1058 ( ) <br /> CITY LINDEN STATE CA rip 95236 <br /> BILLING ACKNOWLEQQJMEN : 1, the undersigned property or business owner, operator or authorized agent of some, <br /> acknowledge that all site andlor project specific EbmRoNMENTAi.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 oartify that I have prepared this application and that the work to be performed will be done in accordance vdth all SAN JOnquiN <br /> COUNTY Ordinance Codes,StandLrdsFDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: 02/06/2018 <br /> PROPERTY I BUSINESS OWNER® ANAGER ® OTHER AuTHoRizED AGENT AUTHORIZED CONiTRACTORIfMPLicANris nproofofaathorizedon#ostgnfsrequired Titre <br /> SWhen applicable, 1, the owner or operator of the property lova o i <br /> site address,hereby auttmrizs the rel of any and all results,geotechnical data andlor environmentallsite a n <br /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it Is pro <br /> my representative. <br /> TYPE OF SERvicE REQUESTED.- <br /> COMMENTS: <br /> EQUESTED:C ENTS: HFq (Jjj�,da�M 0(�j� <br /> To break out existing fill manways(Fiber Lite)and install Phil-Tice 42"multiport manways so fill bucket will hol TAt <br /> 5 gallons on all three tanks. IfftMN7 <br /> AccEPTED BY: Its V1 EMPi oYEE i. DATE: <br /> t8 <br /> ASSIGNED TO: . EMPLOYEE#: DATE: <br /> Date Service Completed (If already completed): SEMACE CODE: ' liP/E: gg <br /> Fee Amount: Amount Paid Payment pate <br /> Payment Type InvoiceCheck# Received By; f <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07117= <br />