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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID # SERVICE REQUEST # Commercial Fueling Cardlock n �?� =, 5 0025297 OWNER / OPERATOR CHECK If BILLING ADDRESS Valley Pacific Petroleum FACILITY NAME Valley Pacific Lodi Plant and Cardlock SITEADDRESS 930 E Victor Road Lodi T95240 Street Number Direction Street Name Ci zi Code HOME or MAILING ADDRESS ( If Different from Site Address) 152 Frank West Circle Street Number Street Name CITY Stockton STATE CA ZIP95206 PHONE #1 EXT, qPN # LAND USE APPLICATION # (209 ) 993 -8793 PHONE #2 EXT. BOS DISTRICT LOCATION CODE (209 ) 948 - 9412 CONTRACTOR / SERVICE REQUESTOR REQUESTOR Mike Eliason CHECK If BILLING ADDRESS BUSINESS NAME PHONE # EXT, ValleV Pacific Petroleum (209 ) 993-8793 HOME or MAILING ADDRESS 152 Frank West Circle , Stockton , 95206 FAX # ( ) CITY STATE ZIP BILLING ACKNOWLEDGEMENT : I , the undersigned property or business owner, operator or authorized agent of same , acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as identified on this form . also certify that I have prepared this application and t at the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes , Standards, STATE: and F - ZA �(is . A P F 1` I , r,r T W r ' r 1A T If P E l _ DATE 10/ 10/2022 PpAoc�ory lei C-S . nC-R I--I OPERATOR / MANAGER ❑/ OTHER AUTHORIZED AGENT ❑ If APPLICANT is not the BILLING PARTY. /hoof of authorization to Sign IS required Title AUTHORIZATION TO RELEASE INFORMATION : When applicable , I , the owner or operator of the property located at the above site address , hereby authorize the release of any and all results , geotechnical data and/or environmental/site assessment Ain�formation to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It IS available and at the same time It Is pro�T�R�VF MENT my representative . RECEII TYPE OF SERVICE REQUESTED : USF hi7 �� COMMENTS : OCT 11 SAN JOAQUIN CC UNTY ENVIRONMENmOAL HEALTH DEPART iAENT ACCEPTED BY : S \ f EMPLOYEE M DATE : V ASSIGNED TO : V '/ EMPLOYEE # : DATE : ,� Date Service Completed - ( if already completed ) : t SERVICE CODE : }' ( P / E :2 Fee Amount : y(J — Amount Paid I� �— Payment Date , p 1 0 cl 20 Z L Payment Type 5 Invoice # Check # / 5 2 Y C S Received By : EHD 48-02-025 SR FORM (Golden Rod ) 07/ 17/08