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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER I OPERATOR <br /> Valley Pacific Petroleum CHECK if BILLING ADDRESS❑ <br /> FACILITY NAME Valley Pacific Petroleum Lodi Plant and Cadlock <br /> SITE ADDRESS 930 E Vidor Road Lodi 95240 <br /> Street Number Direction 1 Street Name Cit Zip Code <br /> HOME or MAILING ADDRESS (if Different from Site Address) 152 Frank West Circle <br /> Street Numtrer Street Name <br /> CITY STATE ZIP <br /> Stockton CA 95206 <br /> PHONE#1 Ex-r. APN# LAND USE APPLICATION# <br /> ( 209 ) 948-9412 322 <br /> PHONE#2 ExT• BOS DISTRICT LOCATION CODE <br /> (209 ) 993-8793 11 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR Mike Ellason CHECK If BILLING ADDRESS❑ <br /> BUSINESS NAME PHONE# EXT. <br /> Valley Pacific Petroleum Services 209 948-9412 <br /> HOME or MAILING ADDRESS FAX# <br /> 152 Frank West Circle ( ) <br /> CITY Stockton STATE CA ZIP 95205 <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 SIGNATU AZE. 1/7/2019 <br /> PROPERTY I BUSINESS OWNER❑ OPERATOR I 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 above <br /> site address, hereby authorize the release of any and all results, geotechnical data and/or environmentallsite asse t information <br /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as Soon a$ It is available and at the Same time It IS l� e or <br /> my representative. clr <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: SqN,/Q 2019 <br /> 11 LtN 01 COU ANN <br /> //�� <br /> n rM�N r <br /> ACCEPTED BY: t{/I EMPLOYEE M q�{}0't DATE: <br /> 7 M 4iv <br /> ASSIGNED TO: DATE: <br /> EMPLOYEE#: <br /> '�.- 1 — <br /> Date Service Completed (if aiready completed): SERVICE CODE: I(� '? PIE: 9 �} <br /> Fee Amount: L Amount Paid G—</ ',�0 Payment Date g/ d <br /> Payment Type ; _ Invoice# Ch ck# r�/� g Received By: <br /> FHD 48-02-025 SR FORM(Golden Rad) <br /> 07/17/08 <br />