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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 � � � � 0 � �� 1'� <br /> OWNER / OPERATOR �lJ p <br /> Chevron Products Company CHECK if BILLING ADDRESSO <br /> FACILITY NAME <br /> Chevron Station Inc . #208118 <br /> SITE ADDRESS <br /> 3355 Street Number DireC[tbn Hammer Lane St ton 9 � e <br /> Street Name <br /> HOME Or MAILING ADDRESS ( If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE #'I EXT, APN # LAND USE APPLICATION # <br /> ( ) RAR Z , 2 <br /> PHONE #2 EXT. BOS DISTRICT / � <br /> H RO �NM IV <br /> CONTRACTOR / SERVICE REQUESTOR - Nr <br /> REQUESTOR <br /> Greg Hohn CHECK If BILLING ADDRESS ® <br /> BUSINESS NAME PHONE # EXT. <br /> Chevron ( 714 671 - 3265 <br /> HOME Or MAILING ADDRESS FAX # <br /> PO Box 2292 ( ) <br /> Cea 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 and FEDERAL laws . ? J <br /> APPLICANT 'S SIGNATURE : - � �� - DATE : l / � �� � l C)) <br /> PROPERTY / BUSINESS OWNER ❑ OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT ® Permit 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 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 2 6 <br /> ENVIRONMENTA HFALTH <br /> pa <br /> ACCEPTED BY : EMPLOYEE # : J T <br /> ) ) <br /> ASSIGNED TO : V Na ' ,1 EMPLOYEE #: GI fcc <br /> ( D� 10ATE : � <br /> Date Service Completed ( if already completed ) : SERVICE CODE : PIE : ro � <br /> Fee Amount : Amount PalCTSt4� OCJ Payment Date 3 <br /> 2711 <br /> Payment Type Invoice # <br /> Check # Receiv d By : <br /> EC $ <br /> D 48-02-025 <br /> OSR FORM (Golden Rod) <br />