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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> -703 U <br /> OWNER f OPERATOR <br /> Valley Pacific Petroleum CHECK If BILLING ADDRESS <br /> FACILITY NAME Valley Pacific Petroleum Hwy 99 Cadlock <br /> SITE ADDRESS 3550 S Hwy 99 Stockton 95206 <br /> Street Number I Direction I Street Name cityV Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) 152 Frank West Circle <br /> Street Number Strset Name <br /> CITY STATE ZIP <br /> Stockton CA 95206 <br /> PHONE#1 ExT. APN# LAND USE APPLICATION# <br /> ( 209 ) 948-9412 322 <br /> PHONE#2 ExT• BOS DISTRICT LOCATION CODE <br /> (209 ) 993-8793 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR Mike Eliason CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> Valley Pacific Petroleum Services 1 209 948-9412 <br /> HOME or MAILING ADDRESS FAX# <br /> 152 Frank West Cirde ( ) <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 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 SIGNATURE: f DATE: 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, I, the owner or operator of the property located the above <br /> site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessmenoyyn <br /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it IS available and at the same time it is; pro l 40 <br /> my representative. (� °09 <br /> TYPE OF SERVICE REQUESTED: -4' <br /> COMMENTS: JO <br /> H�Ty p�pM FNT�N <br /> RTMFN <br /> ACCEPTED BY: t^ EMPLOYEE#: DATE: <br /> ASSIGNED TO: y� I J EMPLOYEE#: / DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: C P I E: 2 C <br /> Fee Amount: Amount Pai �5-,db Payment Date 07 <br /> Payment Type i5�y Invoice# Che # D3� Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />