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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 r��1 A b l C(9 <br /> 0 69 9 �2., <br /> OWNER I OPERATOR v <br /> Fast& Easy CHECK If BILLING ADDRESS <br /> FACILITY NAME Chevron <br /> SITE ADDRESS 10878 1 N Highway 99 Stockton 95212 <br /> Street Number Direction Street Name City Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CIT STATE ZIP <br /> PHONE#1 EXT. APN LAND USE APPLICATION# <br /> ( (209) 931-6154 solD PGD2. <br /> PHONE#2 EXT. BOS DISTRICT 00 <br /> LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR Ronnie Lewis CHECK if BILLING ADDRES <br /> PHONE# EXT. <br /> BUSINESS NAME <br /> Nucleus Pump Services 708 217-4181 <br /> HOME or MAILING ADDRESSFAX# <br /> 601 1st St., Suite B <br /> (707 ) 638-0484 <br /> CITY Sacramento <br /> STATE CA Zip 95818 <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 /> 1 also certify that 1 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: Aeg4ll� DATE: 6/4/18 <br /> PROPERTY/BUSINF,SS OWNER❑ OPERATOR/MANAGER ❑ OTHER AuTuORIZED AGENT Contractor <br /> If APPLK'ANT is not the BILLING PARTY,progf of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1,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 HEALTFI DEPARTMENT as soon as it is available and at thAc�ire time it is <br /> provided to me or my representative. f SIM <br /> AF E/ <br /> TYPE OF SERVICE REQUESTED: VEIM <br /> COMMENTS: Replace diesel 5gal OPW direct bury Spill Bucket. Replace both 91 leak detectors. N 4 5 2418 <br /> SAN 1/rRO 1'N COUN <br /> HST H Df�EmrAt <br /> MFNT <br /> ACCEPTED BY: A ,^a/� EMPLOYEE#: Roo) DATE: b•S - Ile <br /> ASSIGNED TO: , � �� EMPLOYEE#: 1Y ccIt DATE: 6 I <br /> Date Service Completed (if already completed): �� t�"� SERVICE CODE: �C'g P I E: ,r 3D8 <br /> Fee Amount: "I� Amount Paid S'/ O D Payment Date <br /> Payment Type �� Invoice# Check# 3�3 Rec ived By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />