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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 O 0C) 0 O <br /> w0 <br /> OWNER / OPERATOR <br /> Chevron Products Company CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> Chevron Station Inc . #208118 <br /> SITE ADDRESS <br /> 3355 Street Number DlreAbn Hammer Lane Street Name St ton 9§ JAe <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP r <br /> PHONE #1 ExT. APN # LAND USE APPLICATION # Ve <br /> ( ) MAR 2 2 <br /> PHONE #2 EXT. <br /> ( ) BOS DISTRICT H /RC <br /> ON ►� CpBuN� <br /> CONTRACTOR / SERVICE REQUESTOR ��� rMENT <br /> REQUESTOR <br /> Greg Hohn CHECK if BILLING ADDRESS ® <br /> BUSINESS NAME PHONE # EXT, <br /> Chevron 711 671 -3265 <br /> HOME or MAILING ADDRESS FAX # <br /> PO Box 2292 ( ) <br /> Cgrea STAT <br /> ECA 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 . <br /> APPLICANT 'S SIGNATURE : 4K DATE : 1 !2 A <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 /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the same time It IS provided t0 me Or <br /> my representative . <br /> TYPE OF SERVICE REQUESTED : LJ <br /> i <br /> COMMENTS : I' <br /> 4019 <br /> iENVIRONI+AF: �N s11 r�It- ALTH <br /> ACCEPTED BY: EMPLOYEE # : T , h( 7 IL j <br /> ASSIGNED TO : EMPLOYEE # : C ' � (� 0 DATE : <br /> Date Service Completed' ( if already completed ) : SERVICE CODE: \ PIE : k <br /> Fee Amount: L6 Amount Pal CTS�� D � Payment Date 31271141 <br /> Payment Type e17 jvo,� Invoice # Check # Receiv d By : <br /> EHD 48-02-025 SR FORM (Golden Rod) <br /> 07/17/08 <br />