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SAN .JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # SERVICE REQUEST # <br /> Fuel Storage Terminal 2 <br /> OWNER / OPERATOR <br /> NuStar Terminals Operations Partnership , LP CHECK If BILLING ADDRESS <br /> FACILITY NAME NuStar Energy <br /> SITEADDRESS 3505 Navy Drive Stockton 95206 <br /> Street Number Direction I Street Name City Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE #1 EXT. APN # LAND USE APPLICATION # <br /> ( 209 ) 943 -5662 5516 ' (P 2 ® <br /> PHONE #2 ExT. BOS DISTRICT LOCATION CODE <br /> t ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> NuStar Terminals Operations Partnership , LP CHECKif BILLING A ss <br /> BUSINESS NAME NuStar Terminals Operations Partnership , LP PHONE # � T <br /> HOME Or MAILING ADDRESS Same as Owner FAX # ®c j <br /> t ) <br /> CITY STATE ZIP AN ,JogQ <br /> BILLING ACKNOWLEDGEMENT: I , the undersigned property or business owner, operator or authorizel4W � v IN Ty <br /> acknowledge that all Site and/or project Specific ENVIRONMENTAL HEALTH DEPARTMENT hourly Charges associated with this prC7)Z? j <br /> activity will be billed to me or my business as identified on this form . NT <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 SIGNATUR <br /> E : �+�ry DATE : 7 / 14 / 2020 <br /> PROPERTY / BUSINESS OWNER t.] OPERATOR / AANAGER L] OTHER AUTHORIZED AGENT ❑ Terminal Manager <br /> If APPLICANT is not the BILLING PARTY, proof of authorization to Sign IS required Title <br /> AUTHORIZATION TO RELEASE INFORMATION : When applicable , 1 , 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 to me or <br /> my representative . <br /> TYPE OF SERVICE REQUESTED : ' <br /> COMMENTS: <br /> r <br /> ACCEPTED BY : EMPLOYEE #: DATE : <br /> ASSIGNED TO : ee <br /> 1 \ EMPLOYEE #: DATE: <br /> Date Service Completed I e ed ) : SERVICE CODE : P 1 E : <br /> already compl <br /> Fee Amount; 06 Amount Paid � ",ter Payment Date <br /> ix <br /> of <br /> Payment Type ' x Invoice # Check # Received By <br /> a . z <br /> EHD 48-02-025 SR FORM (Golden Rod) <br /> 07/17/08 <br />