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REGE "n, COUNTY RON . �t -aaL' H <br /> SERVICE REQUES,KP2 2017 <br /> Type of Buss & FACILITY ID# SERVICE REQUEST# <br /> G station,`mini mart <br /> �� .r.,. <br /> f�����e l Management <br /> Chevron <br /> SffEADMSS <br /> 33 Pacific Avenue St n 95207 <br /> Zia code <br /> HOME or MAILIN ADWSS Of DWered from M Address) PO Box 1 <br /> N <br /> cmr STATEZIP <br /> Carmichael CA 95" <br /> PHONE#1 APN# LAND USE # <br /> (916)4 <br /> PWNE#2 *• 003 DISTRICT LOCATION Coos <br /> t } <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR. <br /> Greg KaiserBUSINESS C tf ftrLtallo Aoag# <br /> NAME Kaiser Commercial Petroleum PWK2 # 401-2379 <br /> Horm or MARm ADDRESS FIR# <br /> PO Box 1068 t ! <br /> Linden STATE CA ZIP 95236 <br /> 13 UJI12 AG t7 EMNNT: I. the Undersignedproperty or business owner, operator or authorized agent of same, <br /> admowleilge that all site andlor pix:jeot specific EwRoNmENTAL HMTH DEPARTMENT hourly charges with this project or <br /> activity will be billed to nis,or my business as identified on this farm. <br /> I that I have prepared this on that the work to be peribrined will be done In accordance with all SAN JOAQUIN <br /> Codes,COUNTY OA*Nvm StwaWafts,STA F laws. <br /> AP NTS SIGNATURE: "t DATE: 9/1&2017 <br /> PERTY I BUSINESS OWNER13 RIQ mm Ew 'Auth ed Contra r <br /> !f is UNettt PITY . of tion to alga is u Titre <br /> n applicable, 1,the owner or operator of the property loca lid the above <br /> site address,hereby a of any and all results,geolechnical data and/or environmental/site 29" owl affon <br /> to the SM JOAQUIN COUNTY ENviRoNmENTAL HEALTH DEPARTMENT as soon as it is available and at it I <br /> my WT <br /> (M <br /> TYPE oF SER=E REtiU ED; ' <br /> CMUM <br /> • M - �Rp U/N <br /> Replaceall(6)exis#ing dis ers, change k 3 unleaded to diesel,trench,install piping from t <br /> (3)dispensers UDC°s i Smith F piping. <br /> ACCE BY: LoYEE#: DATE: <br /> AssiaNnoTo• YEE 9: DATE: <br /> Date Service CompletedfR alli pfated 0 PIE. <br /> [Payment <br /> .Amon Int Pal 3 <br /> �.(} Paymerrt Date <br /> Typ Invoke# check S f Re By <br /> END <br /> $ -4 SR FORM(Goklen Roo) <br /> a <br /> i <br />