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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID # SERVICE REQUEST # Gas Station 3 i`tA A)PCO5 S ?w B 3 8 5 4 OWNER / OPERATOR Chevron Products Company CHECK If BILLING ADDRESSO FACILITY NAME Chevron Station 372736 SITE ADDRESS VV Lane Stockton 95210 9484 Street Number Direction Street Name City Zip Code HOME or MAILING ADDRESS (If Different from Site Address) PO Box 6004 Street Number Street Name CITY San Ramon STATE CA zIP 94583 PHONE #'I EXT. APN # LAND USE APPLICATION # (925 ) 842-9002 PHONE #2 EXT. BOS DISTRICT LOCATION CODE ( ) CONTRACTOR / SERVICE REQUESTOR REQUESTOR Becky Gallego CHECK If BILLING ADDRESS BUSINESS NAME PHONE # ExT. Wayne Perry 57 262 -8195 HOME or MAILING ADDRESS FAX # 8281 Commonwealth Ave ( > CITY Buena Park STATE CA ZIP 90621 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 that the work to be performed will be done in accordance with all SAN JQAQUIN COUNTY Ordinance Codes, Standards , STATE and FEDERAL laws . APPLICANT ' S SIGNATURE : 6� LAr DATE : 3/ 1 /24 PROPERTY / BUSINESS OWNER ❑ OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT Ppronifflnn SnPC` IAIICf If APPLICANT IS not the BILLING PARTY, proof of authorization to sign is required Title AUTHORIZATION TO RELEASE INFORMATION : When applicable , 1 , 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 ation t0 the SAN JQAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It IS available and at the same time it Is provided tai " my representative . N TYPE OF SERVICE REQUESTED : , � ( hL I / VFX COMMENTS : �'Se res ar r I a eLrrf /jy � ° JL ' / S NJoTq Q ,/6uD� 2l2 � y ySG �pVl O q �� o JAI R4 Ty 4T ACCEPTED BY : T-j--J/ \ ,co " ' EMPLOYEE # : DATE : 0115 /L ASSIGNED TO : � j( �7� ill r Q V �/ EMPLOYEE # : DATE : 3 Date Service Completed ( if already completed) : t f SERVICE CODE : � � PI E : �0; Ds' Fee Amount: AL ¢ r Amount Paid �� Payment Date z 2 v Payment Type Jc (`—, Invoice # Check # 7 { 22 Receiv d By : > l to 017&JI a 17 8 o4bI 1 07/EH EC D /08-02-025 pm ^, l'y �� I�, SR FORM (Golden Rod)