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i <br /> SAN JOAQW COUNTY ENVIRONMENTAL HEALAODEPARTNIENT <br /> SERVICE REQUEST <br /> Type of Business or Property 'FACILITY ID# SERVICE REQUEST# <br /> Commercial Fueling (Cardlock) J� 7 'SKC3b & q f^'0s <br /> OWNER/OPERATOR <br /> Valley Pacific Petroleum Services CHECK if BILLING ADDRESS® <br /> FAcUTYNAME Valley Pacific Charter Way Cardlock <br /> SITE ADDRESS 1501W Charter Way FStockton 95206 <br /> Street Number Direction Street Name city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 188A Frank West Circle <br /> Street Number Street Name <br /> CITY Stockton STATE CA ZIP 95206 <br /> PHONE#1 ExT. APN# LAND USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR Mike Eliason CHECK if BILLING ADDRESSO <br /> BUSINESSNAME Valley Pacific Petroleum Services, Inc PHONE# ExT. <br /> -(209) 993-8793 <br /> HOME or MAILING ADDRESS 188 A Frank West Circle FAX# <br /> ( 209) 948-0755 <br /> CITY Stockton STATE CA ZIP 95206 <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 <br /> or 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 FEDER s_ <br /> APPLICANT'S SIGNA DATE: 3/20/2012 <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ® OTHER AUTHORIZED AGENT❑ <br /> If APPLIc'ANT is not the BILLING PARTY,proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable,I, the owner or operator of the property located at the <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br /> inforniation to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: S <br /> COMMENTS: PAY <br /> RECEIVED <br /> MAR 21 2012 <br /> SAN JOAQU N COUNTY <br /> EWRONMEN7AL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> 2 I fZ <br /> ASSIGNED TO: Q EMPLOYEE#: L DATE: <br /> Date Service Completed eady Completed): SERVICE CODE: <br /> Fee Amount: "—� Amount Paid � :3 1�; r Payment Date �?7'x / 12— <br /> Payment <br /> 2—Payment Type 6 Cid, Invoice# Check# Received By: („(3 <br /> EHD 48-02-025 <br /> SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />