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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID of SERVICE REQUEST II <br /> 4=1 00MYzi-7 <br /> OWNER I OPERATOR <br /> Valley Pacific Petroleum CHECK If g16UNo ADDRESSA <br /> FACILITYHAME ValleyPaeikPeholeum Lodi Plant and Cadlockc <br /> SITE ADDRESS B30 E Victor Road Lodi 95240 <br /> StrIjit GIN 7110 Code51ripel Name <br /> HOME Or MAILING ADDRESS (If Different Tram Site Address) i52 Frank Weal Circle <br /> Strut N4mbStrom Name <br /> CITY Stockton STATE CA ZIP 95206 <br /> PHONE 01 Err. APN# LAND USE APPLICATION <br /> ( 209 ) 948-9412 322 <br /> PHONE 92 ExT. BOS DISTRICT LOCATION CODE <br /> (209 ) 993.8793 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR MikeEliason CHECKif fhLuN0 ADDRESS❑ <br /> BUSINEss NAME PHONE 0 Err. <br /> Valley Pacific Petroleum Services 1 209 948-9412 <br /> HANE or MAILING ADDRESS FAX III <br /> 152 Frank weal Cade ( ) <br /> Cin' 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 andlor project specific EWRONMSNTAL 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 /> 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 SIGNATU � DATE: IW2019 <br /> PROPERTY I BUSINESS OWNER❑ "ryOPERATOR 1 MANAGER ® OTHER AUTHORIZED AGENT ❑ <br /> tf 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 environmentallsite asse t information <br /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as Il is available and at the same time it� laD.Qle Or <br /> my representative. ����//��••RA�*!l� <br /> TYPE DF SERVICE REQUESTED: -14 10D <br /> COMMENTS: 3g1VJ 8 2019 <br /> oAQUr <br /> Hlry DOftPf �N7Y <br /> �+r <br /> ACCEPTED BY: EMPLOYEE : 1 .1 DATE: <br /> ASSIGNED TO: Z_ rj`►/t� ,� EMPLQYEE 1!I: 111 2 DATE: J ,/ <br /> Date Service Completed (if already corrplated): SERVICECODE: 1 C?' ( PIE: <br /> Fee Amount: Amount Paid �9 00 Payment Date <br /> Payment Type V;;5A_ Invoice# Ch ck#6MJ.' GglZ g' Recelved By: <br /> EHD4 202$ JAN �p�g SR FORM(Golden Rod) <br /> +'.LIAL <br />