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RECEIVED <br /> SAN.JOAQUIN COUNTY ENVIRONMENTAL HEALTH DE <br /> ENT <br /> SERVICE REQUEST SEP <br /> Type of Business or Property FACILI IX�f EQUEST# <br /> Gas station, mini mart BONNE IAL , <br /> OWNER/OPERATOR <br /> California Retail Management CHECK if BILLING ADDRESS <br /> FACILITY NAME <br /> Chevron <br /> SITE ADDRESS <br /> 6633 Pacific Avenue <br /> ber Stockton 95207 <br /> Street Numi o ree e <br /> HOME or MAILING ADDRESS (If Different from Site Address) zr e <br /> PO Box 1096 <br /> 3Veet <br /> CITY Number Street Name <br /> Carmichael STATE CA ZIP <br /> PRONE#1 Exr. 95609 <br /> (916)488-3666 APN# LAND USE APPLICATION# <br /> PHONE#2 Err. <br /> ( ) BOS DISTRICT LoCATION CODE <br /> CONTRACTOR SERVICE REQUESTO <br /> REQUESTOR <br /> Greg Kaiser CHECK If BILLING ADDRESS13 <br /> BUSINESS NAME <br /> Kaiser Commercial Petroleum PHONE# ExT. <br /> HOME or MAILING ADDRESS 20 401-2379 <br /> PO Box 1058 FAX# <br /> CITY ( ) <br /> Linden STATE CA 7jP 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 /> 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 <br /> COUNTY Ordinance Codes, Standards, STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: <br /> DATE: 9/18/2017 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR i MANAGER ❑ OTHER AUTHORIZED AGENT 13 Authorized Contractor <br /> If APPLICANT is not the BILLING PARTY.proof Of authorizadOn t0 sign is required <br /> Title <br /> AUTHOR = <br /> TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above <br /> site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information <br /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is provided to me or <br /> my representative. <br /> F <br /> SERVICE REQUESTED:S: <br /> e all (6)existing dispensers, change tank 3 unleaded to diesel, trench, install piping from tank 3 to the front <br /> pensers UDC's with Smith Fiberglass piping. <br /> ACCEPTED BY: <br /> 2iZia <br /> TE: <br /> ASSIGNED TO: <br /> E: <br /> Date Service Completed (if already Completed): <br /> P/E:Fee Amount: Amount PaidPayment Type Invoice# ceived By: <br /> EHD 48-02-025 <br /> 07/17/08 SR FORM(Golden Rod) <br />