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ED <br /> LSAN JOAQUIN COUNTY ENVIRON T <br /> SERVICE REQUESTp p p 20V T 1 b 2017 <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Gas station, mini mart LfACDENVItf�NEMMU� ? <br /> OWNER I OPERATOR [�^,�, p S J44 <br /> California Retail Management C/tlec�clr8R1INE3ADORE ss <br /> FAciutY NAME <br /> Chevron <br /> SITE ADDRESS <br /> 6633 Pacific Avenue Stockton 95207 <br /> SlreetNumber O Street Na a Zl Co • <br /> HOME or MAILING ADDRESS (If Different from Site Address) pp BOX 1096 <br /> Street Number stmetmwe I <br /> CITY <br /> Carmichael STATE CA ZIP95609 <br /> PMK#1 EM APN# LAND USE APPLICATION# <br /> (916)488-3666 <br /> PHS#2 Exr. 808 DISTRICT LOCATION CODE <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUE8TOR <br /> Greg Kaiser CHECK(f BiLuNG ADDR,FFss� <br /> BUSINESS NAME PHONE# Ea <br /> Kaiser Commercial Petroleum (2091 401-2379 <br /> HOME or MARmG ADDRESS FAX# <br /> PO Box 1058 ( ) <br /> CITY Unden <br /> STATE CA ZIP 95236 I <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner, operator or authorized agent of some, <br /> acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or <br /> activity WIN be billed to me or my business as identified on this form. <br /> I also certify that i have preparedWBVu1wGPAR <br /> t the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordh7ancs CodsS,Slandalaws. <br /> APPLICANT'S SIGNATURE; )-�'t—) DATE: 9/18/2017 <br /> PROPERTY/BUSINESS OWNER 0R ❑ OTHER AUTHORIZED AGENT M Authorized Contractor <br /> IF APPLICANT is nof of authorization to sign Is required Ttrie <br /> AUTHORIZATION TO RELEASE INFORMOON:When applicable, 1, the owner or operator of the property loca#Ai the above <br /> sIts address,hereby authorize the release of any and all results,geotechnical data and/or environmentaVsits ass? allon <br /> to the SAN JOAQUIN COUNTY E:NVIRONME<NTAL HEALTH DEPARTMENT 88 soon as it is available and at the same time it IS <br /> my representative. i ?" <br /> TYPE OF SERVICE REQUESTED: <br /> CiOIW1ENTs: 44A, D <br /> y�FN�,,Rooq���iNC <br /> Replace all(6)existing dispensers,change tank 3 unleaded to diesel,trench,install piping ftamtwt;� iyit <br /> (3)dispensers UDC's with Smith Fiberglass piping. r <br /> MFNT <br /> ACCEPTED BY: PA AA Mfb I EMPLOYEE#; DATE: <br /> ASSIGNED To: ZEmPLoyEE#: - <br /> DATE: <br /> DateService Completed (Ifalready comptated SEWCECODE: $ PIE. 3t <br /> Fee Amount• Amount Pat Payment Date <br /> 1.� <br /> Payment Type Invoke# 5-112- R eve <br /> Check# �,. <br /> EHD 48-02-025 <br /> 07/17/08 SR FORM(Golden Rod) <br />