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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # SERVICE REQUEST # <br /> Commercial Fueling Cardlock 67 -� -� <br /> OWNER / OPERATOR <br /> CHECK If BILLING ADDRESS <br /> Valley Pacific Petroleum <br /> FACILITY NAME Hwy 99 Cardlock <br /> SITEADDRESS 3550 S Hwy 99 Stockton 95215 <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 Number Street Name <br /> CITY Stockton STATE CA ZIP 95215 <br /> PHONE #1 EXT . APN # LAND USE APPLICATION # <br /> (209 ) 993 - 8793 <br /> PHONE #2 EXT. BOS DISTRICT LOCATION CODE <br /> (209 ) 948 - 9412 <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR Mike Eliason CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE # EXT. <br /> Valley Pacific Petroleum (209 ) 993 - 8793 <br /> HOME or MAILING ADDRESS 152 Frank West Circle , Stockton , 95206 FAX # <br /> CITY STATE ZIP <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 or <br /> activity will be billed to me or my business as identified on this form . <br /> 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 FEDERAL laws . <br /> APPLICANT ' S SIGNATUR v DATE ; 2 /6/2020 <br /> PROPERTY / BUSINESS OWNER ❑ OPERATOR / MANAGER 13" 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 , I , the owner or operator of the property located at the above <br /> site address , hereby authorize the release of any and all results , geotechnical data and/or environmental/site assessment information <br /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It IS available and at the X8117 wMilrovided to me or <br /> my representative . <br /> RMEIVED <br /> TYPE OF SERVICE REQUESTED : <br /> COMMENTS : FEB <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY : it/ AN /A64 , EMPLOYEE # : DATE : <br /> ASSIGNED TO : 7 EMPLOYEE # : DATE :0 /1/111 ; _ 7jt7 � � <br /> Date Service Completed ( if already completedf. SERVICE CODE : $ P I E : 3 <br /> Fee Amount : 6 oU I Amount Paid Payment Date 2 ,c;;, 2x9 <br /> Payment Type W Invoice # k # b g 0 DO Received By : <br /> or to W f <br /> EHD 48-02-025 SR FORM (Golden Rod) <br /> 07/ 17/08 <br />