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SAN JOAQU*UNTY ENVIRONMENTAL HEALTI WARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Fuel Dispensing Facility 6 00 ,53-1 <br /> OWNER I OPERATOR CHECK If BILLING ADDRESS❑ <br /> Shawn Corporation <br /> FACILITY NAMe rt%oR.PDA <br /> Chevron Fast-N-Easy #60 <br /> SITEDDRESS <br /> 11 78 __ Number DiN. Hwy 99, Front We Road Stockton 95212 <br /> Street rection Sir Name cftv ZiD C <br /> ode <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> SVaet Number Street Name <br /> CITY STATE zip <br /> PHONE#1 Ext. APN# LAND USE APPLICATION# <br /> ( I <br /> C-) f(o_ 0'l O, 02— <br /> PHONE#2 EXT. SOS DISTRICT LOCATION CODE <br /> ( ) i 1 11 Q9 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR CHECK if BILLING ADDRESS <br /> Joseph Bagley BUSINESS NAM PHONE# E'R' <br /> FBagley Enterprises, Inc. 209 367-4800 <br /> HOME or MAILING ADDRESS FAx# <br /> Ste 4 (209 ) 367-5424 <br /> CITY Lodi STATE CA 7JP95240 <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 <br /> or 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,STATIE-alid FEDERAL laws. <br /> APPLICANT'S SIGNATURE: °�`�"` d DATE: O/1///400? <br /> PROPERTY/BUS@IESSOWNER❑ OP. 'OR/MANAGER ❑ OTIIERAUTHORMDAGENM Contractor <br /> IfAPPLrCANT 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 <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. Pq <br /> TYPE OF SERVICE REQUESTED: UST Retrofit CE)VED <br /> COMMENTS: . Replace malfunctioning Leak Detector. '/AN 14 2008 <br /> S EN 1RONME OUNTY <br /> HEALTH DEPgN TENT <br /> ACCEPTED BY: O L t V E( EMPLOYEE#: 31, DATE: / /ly <br /> ASSIGNED TO: A-CZ-�-LL EMPLOYEE M `T IP 3kj DATE: (Z/ I+ c)e <br /> Date Service Completed (N already completed): SERVICE CODE: 4�' 01E: 2.3 p�' <br /> Fee Amount: ��j Amount Paid c ( 4• Payment Date b <br /> Payment Type i/ Invoice# Check# 2 Recel4ed By: \ <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />