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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Gas Station <br /> OWNER/OPERATOR <br /> Bhupinder Uppel CHECK if BILLING ADDRESS <br /> FACILITY NAME Chevron <br /> SITE ADDRESS 1916 E Mar Lane Stockton 95210 <br /> Street Number Direction Street Name Cit Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> ( 209) 954-0945 U 0�J 2 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> Ronnie Lewis CHECK If BILLING ADDRESS <br /> BUSINESS NAME Nucleus Pump Services PHONE# EXT. <br /> 916 382-4761 <br /> HOME or MAILING ADDRESS 601 1st Ave, Suite B FAx# <br /> CITY Sacramento STATE CA ZIP 95818 <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 FEDERAL laws. <br /> APPLICANT'S SIGNATURE: � � 1-0-6vtN - DATE: 6/4/18 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT Contractor <br /> IfAPPLICANT 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 environme- tal/site assessment <br /> m <br /> inforation to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and e time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: VF <br /> COMMENTS: <br /> d0 8 <br /> Veeder-Root cold start. �� <br /> q <br /> NTyoopM��o��� <br /> '9RT,yFNT <br /> ACCEPTED BY: �� ,^ EMPLOYEE DATE: e0 •S• ' Q <br /> ASSIGNED TO: EMPLOYEE#: ov DATE: b ' <br /> 5 1$ <br /> Date Service Completed (if already completed): fit <br /> SERvicE CODE: C(b P 1 E: <br /> Fee Amount: , Amount Paid �D Payment Date <br /> Payment Type Invoice# Check# 337 Rece ved By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />