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ED <br /> SAN JOAQUIIN COUNTY ENVIRON ��` t,' r EPARTME T <br /> SERVICE REQUEST—F p zn T t b 2017 <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Gas station,mini mart fa�IID ' ff tm± <br /> Vljil7� f <br /> OWNERIOPERATOR C)C��11�° ( Iii <br /> Califomia Retail Management CHECK It BILLI�Ki AoDREss <br /> FAcaurr NAME <br /> Chevron <br /> SITE ADDREss <br /> 6633 Pacific Avenue Stockton 95207 <br /> etNnmber D SfraetNa a La Code <br /> HOME or MAILMO ADDRESS (If Different from site Address) PO Box 1096 <br /> Slt+otNumber g <br /> CITY STATE ZIP <br /> Carmichael CA 95609 <br /> Pates i`1 Exr. APN# AND USE ApPucA*noN# <br /> (916)468-3666 <br /> PHtN1E#2 Ea. <br /> { 808 DISTRICT L AT ION CODE <br /> , <br /> j <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR <br /> Greg Kaiser CHECK SLUNGAoDREM <br /> BUSINess NAME PHONE# Exr. <br /> Kaiser Commercial Petroleum 20 401-2379 i <br /> HOME or MAILING ADDRESS FAX# 1 <br /> PO Box 1058 { ) <br /> Cm' Linden STATE CA zip 95236 <br /> BILLING ACKNOVYLEDGEMENT: I,the undersigned property or business owner, operator or authorized agent of same, i <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 prepared this ap 'on an4 that the work to be performed will be done in accordance with all SAN JOA4UlN <br /> COUNTY ordinance Codes,Standards,STa FE laws. <br /> APPLICANT'S SIGNATURE: )- t 1 DATE: 9/1812017 <br /> PROPERTY/BUSINESS OWNER❑ R/MANAGER E3 OTHER AUTFroRmeo AGENT 13 'Authorized Contractor <br /> IFAPFucANT is not 13n tmaG PARTY proof of authorization to sign Is required Tule <br /> At1TiiOR1ZA7iON M RELgASE INFORMAION:When applicable, 1, the owner or operator of the property;1ocaitthe abovesite address,hereby authorize the release of any and all results,geotechnical data and/or en lronmentavaite as ation <br /> to the Sara Joaauaav CoutvTr EraVlRowtwElvTAL HEALTH DEPARTMENT as soon ais it is available and at the same time i <br /> my representative. Ill <br /> TYPE OF SERVICE REQUESTED: <br /> C �® <br /> Replace all(6)existing dispensers,change tank 3 unleaded to diesel,trench,instali piping from C 't <br /> (3)dispensers UDC's with Smith Fiberglass piping. r" <br /> MFMT I <br /> ACCEPTED BY: I.--. EMPLOYEE#: t DATE <br /> ASSIGNEE TO: EMPLOYEE#: DATE:! - <br /> Date Service Completed (ifalready coanpt®ted . SEVICECON: Q PIE: 3 7 <br /> Fee Amount <br /> • Amount Pa( <br /> �,DD Payment Date <br /> t�aym®nt Type Invoice# Check Rs ve By - <br /> EHD 48-02-025 <br /> 07117/08 SR FORM(sodden Rod) <br /> 9 <br /> 1 <br />