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SAN JOAQOCOUNTY ENVIRONMENTAL HEALTIOPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> GAS STATION/MINI MART Q O ?j 5K <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> CALIFORNIA RETAIL MANAGEMENT <br /> FACILITY NAME <br /> CHEVRON <br /> SITE ADDRESS <br /> 6633 PACIFIC AVENUE STOCKTON 95207 <br /> Street Number I Direction I Street Name City 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 ExT• APN# LAND USE APPLICATION# <br /> (916) 488-3666 <br /> PHONE R ExT• BOS DISTRICTLOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> GREG KAISER CHECK if BILLING ADDRESS X <br /> BUSINESS NAME PHONE# ExT. <br /> KAISER COMMERCIAL PETROLEUM 209 401-2379 <br /> HOME or MAILING ADDRESS FAx# <br /> PO BOX 1058 ( ) <br /> CITY LINDEN STATE CA ZIP 95236 <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific ENVIRONMENTAL 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 /> also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards, ST a FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: 02/06/2018 <br /> PROPERTY/BUSINESS OWNER❑ PERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ® AUTHORIZED CONTRACTOR <br /> If APPLICANT is not tI1 ILLING PARTY,proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property locatekA <br /> site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assess � P0.7' <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. Fr, p" <br /> TYPE OF SERVICE REQUESTED: 5,q�, 2016 <br /> COMMENTS: / TSI�CNMOUN <br /> To break out existing fill manways(Fiber Lite)and install Phil-Tite 42" multiport manways so fill bucket will h r�T'1� <br /> 5 gallons on all three tanks. MFNT <br /> ACCEPTED BY: UWA �/♦f d1 EMPLOYEE#: DATE: ,t r1 nl <br /> ASSIGNED TO: / ', ,--1 EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: 1 PIE: 309 <br /> Fee Amount:fn�l I Amount Paid /S'O•UD I <br /> Payment Date I' <br /> Payment Type r :s Invoice# Check# Received By: <br /> K, S <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />