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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> GDF A oalq 1, <br /> OWNER/OPERATOR r f <br /> Vikas C.Patel CHECK if BILLING ADDRESS <br /> tl <br /> FACILITY NAME <br /> West Valley Auto Spa Chevron <br /> SITE ADDRESS West Grant Line Rd. Tracy 95304 ,\ j� �I <br /> 2615 Street Number Direction Street Name Cit Zi Code V 2� <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (209 ) 836-3464 2 101.7IWI <br /> Pq�, <br /> PHONE#2 EXT. BOS DISTRICT L pE <br /> ( ) I V <br /> CONTRACTOR / SERVICE REQUESTOR t 3 0 <br /> REQUESTOR JOA <br /> Karli Kaarns CHECK i <br /> BUSINESS NAME PHONE# H pAR <br /> Confidence UST Services, Inc. 661 631-3870 ENT <br /> HOME or MAILING ADDRESS FAX# <br /> 16250 Meacham Road (661 )587-9758 <br /> CITY STATE ZIP <br /> Bakersfield CA 93314 <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: & /l <br /> - <br /> a4 id DATE: 10/25/2018 <br /> PROPERTY I BUSINESS OWNER❑ OPERATOR I MANAGER ❑ OTHER AUTHORIZED AGENT Q Dispatch,Confidence UST Svcs. <br /> If APPLICANT IS not the BILLING PARTY, proof 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 above <br /> site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information <br /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the same time It IS provided t0 me Or <br /> my representative. a <br /> Emb I-- <br /> TYPE OF SERVICE REQUESTED:Replace and retest test boots in UDC's 1/2,9/10,&11/12. " <br /> COMMENTS: J <br /> OCT 2 2018 <br /> ENVIRONMENTAL HE•`.wi H <br /> DEPARTMENT <br /> ACCEPTED BY: u EMPLOYEE#: , DATE: I(J.���•�I (?, <br /> ASSIGNED TO: �1��•`l, � EMPLOYEE#: �)l} DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: ' C� PIE: <br /> Fee Amount: I5v Amount Paid � (O ,0d Payment Date <br /> Payment Type C� Invoice# ( Check# /1f375 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />