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SERVICE REQUEST Type of Business or Property FACILITY ID # BILLING PARTY X1 SERVICE REQUEST SERVICE STATION BUSINESS NAME OWNER/ OPERATOR BILLING PARTY CHEVRON PRODUCTS COMPANY (7 07 579-0250 'CT'T�IAWSERVICE STATION RATE: SITE ADDRESS 2155 NYLA PLACE SERVICE CODE: 07 575-7389 �TNTA ROSA -.0 STATE zip C A 95401 301 � W KETTLEMAN LANE Check #, TReceived ST. Street Number .T Street Name Type Swe 4 Mailing Address (If Different from Site Address) CHEVRON PRODUCTS COMPANY CITY STATE zip PO BOX 5004 SAN RAMON, CA 95401 PHONE #1 APN# LAND USE APPLICATION # '3 xxExr. X25)842-9083 045-140-02 PHONE #2 EXT. BOS DISTRICT LOCATION CODE CONTRACTOR/ SERVICE REQUESTOR REQUESTOR BILLING PARTY X1 MUSCO EXCAVATORS, INC. BRYAN H. MUSCO CONTRACTOR'S SIGNATURE: BUSINESS NAME PHONE# MUSCO EXCAVATORS, INC. ASSIGNED TO: (7 07 579-0250 MAILING ADDRESS RATE: FAx # 2155 NYLA PLACE SERVICE CODE: 07 575-7389 �TNTA ROSA -.0 STATE zip C A 95401 BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner, operator or auth"ed agent of same, acknowledge that all site and/or project specific PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DmsioN hourly charges associated with this project or activity will be billed to me or my business as identified on this form. 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 COUNTY Ordinance Codes, Standards, STATE and FEDERAL faws. 7/13/98 APPLICANT SIGNATURE: DATE. PROPERTY / BUSINESS OWNER 0 OPERATOR/ MANAGER 0 OTHER AUTHORIZED AGENT )t PRESIDENT If ApRrwT is not the Bunn PAar r, proof of authod=don 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 environmentalisite assessment information to the SAN JOAQUIN COUNTY Puauc HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as Soon as it is available and at the same time it is provided to me or my representative. TYPE OF SERVICE REQUESTED: UST REMOVAL COMMENTS: INSPECTOR'S SIGNATURE' CONTRACTOR'S SIGNATURE: Aw- P R 0 1 PrE 0 SY: EMPLOYEE t DATE: ASSIGNED TO: EMPLOYEE # RATE: Date Service Completed (if already complIeted):P SERVICE CODE: i E: Fee Amount: Amount Paid Payment Date Payment Type Invoice 9 Check #, TReceived ST. r