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RECOUEONTY:EWRONLIAELJ �►�,PM DEPA'RtJT <br /> SERVICE REQUESFf' 0 2017 <br /> Type of Business or FACILITY ID III SERVICE REQUEST i <br /> Gas station,mini mart FPI�O2- Ej�1R0NK4r' r1i'Tr'A0 ( "7 <br /> g^^ :-1 ( rr <br /> O iJi�t'r i' € LJta.:l`' If8lLUNOAn eta <br /> II management <br /> FAam NAME <br /> Chevron <br /> SITE ss <br /> 3 Pacific Avenue Stockton 95207 <br /> 111111ft RWON — cftv _LAL22ft_ <br /> E Or MAILMG ADDRESS Of Diflaient from SM Ad ) <br /> PD Box 1096 <br /> CITY STATE ZIP <br /> CA 95609 <br /> PMK#1 Exr. APN# <br /> LANs tfBE AP <br /> (916)468-3 <br /> Nola f2 Mr. <br /> 609 TpicT LOCATION CoDe <br /> { <br /> CONTRACTOR/SERVICE Q R <br /> I�QU <br /> Greg Kaiser cm=if BUM A2Q= <br /> Ezr. <br /> BusiNEss NAME Kaiser Commercial Petroleum (2091 <br /> 401-2379 <br /> HoaaorMAL=ADDREssFAX i <br /> PO 1058 <br /> { ) <br /> CITY Linden STATE CA 2� 95236 <br /> MUM ACKNf? 9090M1 t, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowkWoe that all silte andlor project specitic ENVIRONMENTAL HEALTH DEPARTMENT hourly charges with this Project or <br /> activity will be billed to me or my basin as identified on this farm, <br /> I also certify that I have Prepared this on an that the work to be Performed will to done in aomdance with all SAN JOAQUIN <br /> COUNTy CrOuLnce Codes,Standwds,STA F RAL <br /> AP T'S SIGNATURE: DATE: 9118/2017 <br /> PROPERTY t Bu ❑ : ATbra I R E3ERA AQENT 'Authorized contractor <br /> If T IS JW f DAUSLESM proof Of 8uffmksftn to 99n is requked Title <br /> A Z&Mo TO t ReRF®ne-QBM <br /> ,��, en applicable, 1,the owner or operator of the property above <br /> site add ,hereby authorim the release of any and all results,geotechnical or en ental! ass ation <br /> to the SAN N COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is availableandat the samefte it <br /> my representative. <br /> ----------- <br /> TYPE oF SomE REouESTED: <br /> �r 41 <br /> Srp 11, <br /> Rept all(6)existing dispensers, change tank 3 unleaded to diesel,trench,Install piping from t <br /> (3)dispensers UDC°s With Smith Fiberglass piping. <br /> ACCEPTED BY: YEE S: <br /> DATE: <br /> ®NEe To. ENIPLO <br /> EMPLOYEE#: DATE: <br /> DateS Compl (If conapf _ CODE: PIE: <br /> Fee.Amou Amount Pat6.6 j� Payment tate <br /> Payment Typ Invoice# Check# R By <br /> EHD48-0240 <br /> 07/17 SRF (Goidw Rod) <br /> i <br />