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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY IID # SERVICE REQUEST # <br /> 10182167 FAOOWO 30 S 14 <br /> OWNER / OPERATOR CHECK if BILLING ADDRESS <br /> Valle Pacific Petroleum Services <br /> FACILITY NAME <br /> Valle Pacific Hvv99 Cardlock <br /> SITE ADDRESS 3550 S Hwy 99 Stockton 95206 <br /> Street Number Direction Street Name Cit Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 152 Frank West Circle <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> Stockton CA 95206 <br /> PHONE #1 EXT• APN # LAND USE APPLICATION # <br /> ( 209 ) 948 -9412 <br /> PHONE #2 EXT. BOS DISTRICT LOCATION CODE <br /> ( 9nq 993-8793 <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR Nic Poblano CHECK if BILLING ADDRESS ® <br /> BUSINESS NAME PHONE # EXT. <br /> Valley Pacific Petroleum Services 209 639 -2191 <br /> HOME or MAILING ADDRESS FAX # <br /> 152 Frank West Circle ( ) <br /> CITY Stockton STATE CA Zip 95206 <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 /> 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 : DATE : <br /> PROPERTY / BUSINESS OWNER ❑ OPERATOR I MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <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 Aded to me or <br /> my representative . � '� <br /> TYPE OF SERVICE REQUESTED : Ct' <br /> COMMENTS : t9 <br /> 1p <br /> SAN ,✓® 2021 <br /> �fy '1QUf <br /> Nth H UFp! RTr CN7Y <br /> ANT <br /> ACCEPTED BY : ` R ; � ecj EMPLOYEE #: DATE : <br /> ASSIGNED TO : EMPLOYEE # : DATE : <br /> Date Service Completed (if already completed) : SERVICE CODE : ( vl (, P I E : a 309 <br /> Fee Amount : 45 & Amount Pal �� Payment Date <br /> Payment TypejpA it I Invoice # Check # 7 Z Received By: <br /> EHD 48-02-025 SR FORM (Golden Rod ) <br /> 07/17/08 <br />