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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 J� O Oo Q o L L.� c2v I'y�) <br /> OWNER/OPERATOR U 1 �JIJ p <br /> Chevron Products Company CHECK if BILLING ADDRESSO <br /> FACILITY NAME <br /> Chevron Station Inc.#208118 <br /> SITE ADDRESS FF <br /> 3355 Street Number Direggn Hammer Lane St ton �e <br /> Street Name <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name PA Vq. <br /> CIN STATE Zip RF r <br /> PHONE#1 EXT. ApN# LAND USE APPLICATION# •` <br /> ( ) el <br /> MAR ?� 2 <br /> PHONE#T EXT. BOS DISTRICT I µCp� <br /> 11—.1-1 ROHM c UNrY <br /> CONTRACTOR /SERVICE RE, QUESTOR r <br /> REQUESTOR <br /> Greg Hohn CHECK if BILLING ADDRESS® <br /> BUSINESS NAME PHONE# EXT. <br /> Chevron 71 671-3265 <br /> HOME or MAILING ADDRESS FAX# <br /> PO Box 2292 ( ) <br /> Cffrea STATECA Zip 92822 <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 /> 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 <br /> Eaand <br /> dFFEDERAL laws. <br /> APPLICANT'S SIGNATURE: � ��/ DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ® Permit Agent <br /> If APPLICANT Is not the BILLING PARTY proof of authorization f0 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 Same time it is provided to me Or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: ` <br /> COMMENTS: <br /> MAR <br /> ENVIRONM( r1'1`,t1f I-It-AMI <br /> ACCEPTED BY: EMPLOYEE#: • T Il {, 162- <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed' (if already completed): SERVICE CODE: \ PI E: n n <br /> Fee Amount: Amount PailCT�(O.6D Payment Date 3� AOS Cl <br /> Payment Type cy <br /> Invoice# Check# Received By: <br /> EHD 48-02-025 <br /> 07/17/08 SR FORM(Golden Rod) <br />