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SAN JOAQUIN (:OUNTY ENVIRONMENTAL HEALTH 11PARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID # SERVICE REQUEST # CHECK ifBILUNGAEMM BUSINESS NAME Valley Pacific Petroleum Services PAYMENT RECEIVED OWNER /OPERATOR Valley Pacific Petroleum Services CHECK if BILLING ADDRESS❑ FACILITY NAME Valley Pacific Petroleum - Charter Way Cardlock SAN JOAQUIN COUNTY SITE ADDRESS 1501 W Charter Way I Stockton 95206 Street Number Direction Street Name ASSIGNED TO: city Zh) Code HOME or MAILING ADDRESS (If Different from Site Address) 188 A Frank West Circle Street Number ady completed): Street Name CIN Stockton STATE CA Zip 95206 PHONE #1 EXT. APN # LAND USE APPLICATION # ( 209 > 948-8412 Amount Paid . 60 PHONE #2 EXT. SOS DISTRICT LOCATION CODE (209 ) 993-8793 11 Check # CONTRACTOR / SERVICE REQUESTOR REQUESTOR Mike Eliason CHECK ifBILUNGAEMM BUSINESS NAME Valley Pacific Petroleum Services PAYMENT RECEIVED PHONE# EXT. DEC! 3 0 2010 (2 09 993-8793 HOME or MAILING ADDRESS SAN JOAQUIN COUNTY FAX # 188 A Frank West Circle HEALTH DEPARTMENT ( 559) 732-0817 CITY Stockton STATE CA ZIP 95206 BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as identified on this form. 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 COUNTY Ordinance Codes, Standards, STATE and FFE ERAL Ws. APPLICANT'S SIGNATURE: �`''" DATE: 12/29/2010 PROPERTY / BUSINESS OWNERD OPERATOR/ MANAGER ® OTHER AUTHORIZED AGENT D ff APPLICANT is not the BILLING PARTY. proof of authorization to sign is required Title AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information 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 my representative. TYPE OF SERVICE REQUESTED: COMMENTS: PAYMENT RECEIVED DEC! 3 0 2010 SAN JOAQUIN COUNTY a.. _._.ENVIRONMENTAL HEALTH DEPARTMENT ACC TED -Y:'" EMPLOYEE #:--�� DATE:�� ASSIGNED TO: EMPLOYEE #: DATE: Date Service Completed (if al ady completed): SERVICE CODE: F1 E:.? O� Fee Amount: Gs� Amount Paid . 60 Payment Date c3 g p Payment Type vC� Invoice # Check # Rec ived By: PJ r � EHD 48-02-025 1 %� SR FORM (Golden Rod) REVISED 11/17/2003 U