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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 FA0000485 1�3e <br /> OWNER / OPERATOR <br /> CHECK If BILLING ADDRESS <br /> 5RIVERS FUEL , INC . / AZAD AMIRI <br /> FACILITY NAME <br /> FLAG CITY CHEVRON <br /> SITE ADDRESS WEST CAPITOL AVENUE LODI L95242 <br /> 6421 Street Number Direction Street Name City Zie Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE #1 EXT. QPN # LAND USE APPLICATION # <br /> ( 925 ) 646-3635 <br /> PHONE #2 EXT, BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR " <br /> CHECK If BILLING ADDRESS <br /> KARLIKARNS <br /> BUSINESS NAME PHONE # EXT, <br /> CONFIDENCE UST SERVICES , INC . 661 631 -3870 <br /> HOME or MAILING ADDRESS FAX # 587-9758 <br /> 16250 MEACHAM ROAD ( 661 ) <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 �FFEiEDERAL laws . <br /> APPLICANT ' S SIGNATURE : / 1a&1& /wIa44z. DATE : 03/05/2019 <br /> PROPERTY I BUSINESS OWNER ® OPERATOR / MANAGER ® OTHER AUTHORIZED AGENT Q DISPATCH , CONFIDENCE UST <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 IS provided t0 me or <br /> my representative . <br /> TYPE OF SERVICE REQUESTED : REPLACE EXISTING DISPENSERS WITH NEW GILBARCO ENCORE 700S ; INSTALL BRAVO ADAPTson 6E <br /> COMMENTS : R410�, <br /> MAR 0 8 2019 yo <br /> ENVIRONMENTAL NEALTN �R° G�ti 2�I9 <br /> PERMIT/ �FA�F,�OG <br /> ACCEPTED BY : }� _ EMPLOYEE DATE: J� <br /> ASSIGNED TO : rvk EMPLOYEE # : i f DATE: 3J <br /> 1 - <br /> Date Service Completed (if already completed) : SERVICE CODE: \ I Igo PIE : a(,2 <br /> Fee Amount : Amount Pai '1 S6t�� Payment Date 3 <br /> Payment Type �� Invoice # Check # �5�3 � Received By . <br /> EHD 48-02-025 SR FORM (Golden Rod) <br /> 07/17/08 <br />