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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> SERVICE STATION -Act g,r6 tI <br /> OWNER/OPERATOR <br /> CHEVRON PRODUCTS COMPANY CHECK If BILLING ADDRESS❑ <br /> FACILITY NAME CHEVRON SS#9-9840 <br /> SITE ADDRESS 4344 E WATERLOO ROAD STOCKTON 94506 <br /> Street Number Direction Street Name city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 30 MAIN AVE. SUITE 5 <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> SACRAMENTO CA 95838 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> ( 916 ) 646-9680 1616 cj <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR MERLIN BOWEN(AGENT FOR CONTRACTOR-WAYNE PERRY) CHECK if BILLING ADDRESSO <br /> BUSINESS NAME WAYNE PERRY,INC. PHONE# EXT. <br /> 916 646-9680 <br /> HOME or MAILING ADDRESS FAx# <br /> 30 MAIN AVE. SUITE 5 ( 916 ) 646-9683 <br /> CITY SACRAMENTO STATE CA ZIP 95838 <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,STATE and FEDERAL laws. ` <br /> APPLICANT'S SIGNATURE: 7��'/Ia���W_ �1/1y7 '� J DATE: I IZ41920 <br /> PROPERTY/BUSINESS OWNER❑ ,OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT W gen for Owner <br /> If ADPL/CANT 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. <br /> TYPE OF SERVICE REQUESTED: REPLACE EXISTING DISPENSERS with CONVERSION FRAMES t)� <br /> COMMENTS: PAYMENT <br /> INSTALL NEW DRESSER WAYNE B-12 DISPENSERS WITH CONVERSION FRAMES <br /> �"7CEIVED <br /> !AN 2 2 2016 <br /> ,QUIN COUWY <br /> ;ONMENTAL <br /> 7EPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: DATE:Crk <br /> _ <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: C' PIE: <br /> Fee Amount: _► j Amount Paid '3 v �� Payment Date l ,6L�;I, l <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />