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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 S R CIS 0 93 5(D q <br /> OWNER/OPERATOR <br /> Chevron Products Company CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> Chevron 99840 <br /> SITE ADDRESS E Waterloo Stockton 95215 <br /> 4344 Street Number Direction I Street Name City Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> PO Box 6004 Street Number Street Name <br /> CIT.' San Ramon STATE CA ZIP 94583 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> ( ) <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> Beck Gallego CHECK If BILLING ADDRESS <br /> BUSINESS NAMEPHONE# EXT. <br /> Wayne Per 57) 262-8195 <br /> HOME or MAILING ADDRESS FAX# <br /> 8281 Commonwealth ( ) <br /> CITY Buena Park STATE CA ZIP 90621 <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 /> 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: DATE: 12/4/23 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MAaAGER ❑ OTHER AUTHORIZED AGENT `d Permitting Coordinator <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 prOyuled to me or <br /> my representative. fAYlopm'r <br /> TYPE OF SERVICE REQUESTED: �l J"�/ t}"{� NI�CC `I D <br /> COMMENTS: �% DEC 2 7 20 <br /> SAN <br /> ENJORo SIN CO <br /> HEALTH DE ARTM NTY <br /> ACCEPTED BY: C 9/�//� '- EMPLOYEE#: DATE: ) <br /> ASSIGNED TO: n �G�r f EMPLOYEE#: DATE: -�/ 01-2—--3 <br /> '774 <br /> Date Service Complete (if already completed): 7 3 SERVICE CODE: lq�,;2qf <br /> P I E:�23O1 <br /> Fee Amount: cif � p- tA Amount Pai 2 U0 Payment Date ' Z <br /> Payment Type t-� Invoice# Check# 3 Receive By: <br /> 237 -3 EHD 48-02-025 I �} ' SR FORM(Golden Rod) <br /> 07/17/08 <br />