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SAN JOAACOUNTY ENVIRONMENTAL HEALTAPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Gas Station M00a1,7q— <br /> OWNER/OPERATOR b5 l �i> <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME Western Food & Fuel <br /> SITE ADDRESS Waterloo Rd. Stockton 95205 <br /> 3032 Street Number I Direction I Street Name city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 4895 S. Airport Way <br /> Street Number Street Name <br /> CITY Stockton STATE CA ZIP 95206 <br /> PHONE#'I —7--77APN# LAND USE APPLICATION# <br /> ( ) 916 442-0076 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR Ronnie Lewis CHECK if BILLING ADDRESS <br /> BUSINESS NAME Nucleus Pump Services <br /> PHONE# ExT• <br /> 916 382-4761 <br /> HOME or MAILING ADDRESS 601 1 st Ave.,Suite B FAx# <br /> (707 )638-0484 <br /> CITY Sacramento 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 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: 10/17/18 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT Contractor <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 I$,p[�Vj( I . r or <br /> my representative. ix mCnll 0 <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: OCT 18 2018 <br /> Replace OPW direct bury spill bucket. <br /> SAN JOAQUIN COUNT <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMEN <br /> ACCEPTED BY: EMPLOYEE#: '� DATE: <br /> ASSIGNED TO: i v EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: I PILE: '-2_,3'019 <br /> Fee Amount: 14-�Z- Amount Paid ��-- Payment Date p v z <br /> Payment Type Invoice# Check# J Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />