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i SAN JOAOUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST - Type of Business or Property FACILITY ID It SERVICE REQUEST 0 GDF FA0000485 % IJ � dJ 32C5 OWNER / OPERATOR 6f11VERS FYE6�;�rA;�ADAMIFt1 Star Holdings , LLC dba Flag City Chevron CHEC!( IfBILLINGADDRESS ® FACILITY NAME Star Holdings , LLC dba Flag City Chevron SITEADDRESS WEST CAPITOL AVENUE LODI 95242 6421 Street Number Direction Street Name City Zip Code HOME or MAILING ADDRESS ( If Different from Site Address) Street Number Qt ieet Name CITY STATE ZIP PHONE #1 Err. APN # LAND USE APPL16ATION 2019 ( 925 ) 646-3635 21 7 PHONE 112 EXT. BOS DISTRI1, C TJ C DE ( ) `ENVIRON L 71 � �ILAL:1 H CONTRACTOR / SERVI4 E REQUESTOR R 11 ENT REQUESTOR " KARLI KARNS CHECK if BILLING ADDRESS BUSINESS NAME PHONE ft EXT. CONFIDENCE UST SERVICES , INC. 661 631 -3870 HOME or MAILING ADDRESS FAX it 16250 MEACHAM ROAD ( 661 ) 587-9758 CITY STATE ZIP BAKERSFIELD CA 93314 BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same , acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as identified on this form . 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 COUNTY Ordinance Codes, Standards, STATE and lot laws. APPLICANT' S APPLICANT' S SIGNATURE : a4 & 1, a4 zelL DATE ; 03/05/2019 PROPERTY / BUSINESS OWNER ® OPERATOR / MANAGER ® OTHER AUTHORIZED AGENT DISPATCH , CONFIDENCE UST If APPLICANT is not the BILLING PARTY proof of authorization to Sign is required Title AUTHORIZATION TO RELEASE INFORMATION : When applicable, I , the owner or operator of the property located at the above site address , hereby authorize the release of any and all results , geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as Soon as It is available and at the same time it is provided t0 me Or my representative . TYPE OF SERVICE REQUESTED : REPLACE EXISTING DISPENSERS WITH NEW GILBARCO ENCORE 700S ; INSTALL BRAVO ADAPTE COM1IM1IENTS: KMAZIftij MAR 0 8 2019 ti %Jo �� /,� EAVIRONMENTAL HEAL TFf �N9FNOG PERMIT/ �FA� ACCEPTED BY : E _ ma EMPLOYEE #: /� ( 1 DATE: � " ti `lYV ASSIGNED TO : F� *v /Ln EMPLOYEE #: DATE: 3 . � , �/ Date Service Completed (if already completed) : SERVICE CODE: ( P II E : a( 2 Fee Amount: QtI Amount Pai L7�7�G. M6 Payment Date 3 A Payment Type Invoice it Checic # �Sj�3Received By : EHD 48-02-025 SR FORM (Golden Rod) 07/17/08