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' SAN JOAQUWOUNTY ENVIRONMENTAL HEALTOEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Commercial Fueling (Cardlock) Odq-aL+ <br /> OWNER/OPERATOR 11 <br /> Valley Pacific Petroleum Services, Inc. CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> Valley Pacific Charter Way Cardlock <br /> SITE ADDRESS 1501W Charter Way Stockton 95206 <br /> Street Number Direction Street Name city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 152 Frank West Circle <br /> Street NumberF Street Name <br /> CITY Stockton STATE CA ZIP 95206 <br /> PHONE#t ExT. APN# [BOS <br /> AND USE APPLICATION# <br /> (209 ) 948-9412 l(P' 7 � <br /> PHONE#2 ExT DISTRICT LOCATION CODE <br /> (209 ) 993-8793 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR Mike Eliason <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> valley Pacific Petroleum Services, Inc. 209 993-8793 <br /> HOME or MAILING ADDRESS FAX# <br /> 152 Frank West Circle ( 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,STATF and FF,DF,RAL laws. <br /> APPLICANT'S SIGNATURE: i/; ', DATE: &/11/2015 <br /> PROPERTY/BUSINESS OWNER[3 OPERATOR/MANAGER ® OTHER AUTHORIZED AGENT❑ <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1,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 /> information 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 SER"PAYMENT ' <br /> COMMENTS: RECEIVED <br /> JUN 12 2015 <br /> SAN JOAQUIN COUNTY <br /> ENVIROMENTAL <br /> HEALTH DEPA NT <br /> ACCEPTED BY: - EMPLOYEE#: DATE: <br /> ASSIGNED TO: r, `ve+-y( EMPLOYEE#: DATE: — <br /> Date Service Completed (if already completed): SERVICE CODE: P 1 E: <br /> Fee Amount: C��(�-(j Amount Paid 3 01 tJ CP Payment Date <br /> Payment Type J;S Invoice# Check# Received By: e J r� <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />