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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # § ERVICE REQUEST # <br /> Gas StationrA0000ew 2Z - � vP7 <br /> OWNER / OPERATOR Chevron Products Company P Y CHECK If BILLING ADDRESS <br /> FACILITY NAME Chevron # 94275 <br /> SITE ADDRESS 2905 W West Benjamin Holt Dr Stockton 95207 <br /> Street Number Direction I Street Name City Zip Code <br /> HOME or MAILING ADDRESS ( If Different from Site Address) Bollinger Canyon Rd <br /> 6001 Street Number :street Name <br /> CITY San Ramon STATP ZIP <br /> CA 94583 <br /> PHONE #1 EXT• APN # LAND USE APPLICATION # <br /> ( ) <br /> PHONE #2 EXT, BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR Tony Baiady CHECK If BILLING ADDRESSLJ <br /> BUSINESS NAME Wayne Perry Inc PH^ki= EXT' <br /> ( 916 - 646 - 8680 <br /> HOME or MAILING ADDRESS 30 Main Ave Suite 5 FAx # <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 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 aws . <br /> APPLICANT' S SIGNATURE : DATE : 09 / 28 / 2020 <br /> PROPERTY / BUSINESS OWNER El OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT L Project Manager <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 /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the Same tiPAP�I IS provided to me or <br /> my representative . 1"H )/47e 114zc c <br /> TYPE OF SERVICE REQUESTED : C/I Vto <br /> COMMENTS : SEP <br /> 0 2920 SA <br /> AFN 0&4 C <br /> yFALTy pEpAa AL Y <br /> ACCEPTED BY: ( ` ,f� 1 /� /� �J EMPLOYEE #: DATE : �a <br /> ASSIGNED TO : v` // / v , /j h Q/ EMPLOYEE #: DATE : <br /> p eg _fin Z� <br /> Date Service Completed I already comted ) : ` SERVICE CODE : PIES <br /> Fee Amount : y L� Amount Pal 7-0w� � 00 Payment Date <br /> rPaymentType Invoice # Check # Receiv d By : <br /> EHD 48-02-025 SR FORM (Golden Rod) <br /> 07/ 17/08 <br />