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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 FA0003720 S� C )033 &,�S7 <br /> OWNER / OPERATOR <br /> CHECK If BILLING ADDRESS <br /> I <br /> FACILITY NAME <br /> Charter Way Chevron <br /> SITE ADDRESS Stockton 95206 <br /> 508 Dr. Martin Luther King Jr. Blvd . <br /> Street Number Direction 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 #'I ExT, APN #U LAND USE APPLICATION # <br /> PHONE #2 ExT. 1 BOS DIST IC LOCATION CODE <br /> ( ) F7 <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR James Otto CHECK If BILLING ADDRESS ® <br /> BUSINESS NAME LC Services PHONE # ExT. <br /> 559 444- 1730 <br /> HOME or MAILING ADDRESS 3887 N . Valentine Ave , FAx # <br /> CITY Fresno STATE CA ZIP 93722 <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 : O&E� DATE : 4/7/2021 <br /> PROPERTY / BUSINESS OWNER ❑ OPE TOR 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 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 tlrT� lb I�,provided to me or <br /> my representative . f^�I J' M <br /> TYPE OF SERVICE REQUESTED : V / <br /> COMMENTS : / <br /> SA / coy ?021 <br /> q <br /> hEA TH D p 11 r � <br /> T MINT <br /> ACCEPTED BY: 1 EMPLOYEE # : DATE : rJ / <br /> ASSIGNED TO : v EMPLOYEE # : �/]� DATE : <br /> Date Service Completed ( if already completed ) : SERVICE CODE : q- 9 PIE : UQI <br /> Fee Amount : TA!/ 4 (� Amount Paid g4 Payment Date <br /> Payment TypeInvoice # Check # ` Recei ed By <br /> EHD 48-02-025 SR FORM (Golden Rod) <br /> 07/17/08 <br />