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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # SERVICE REQUEST # <br /> a(6 At Ca= A 10182249 �� 1jr, ' <br /> OWNER / OPERATORrrOT <br /> Valley Pacific Petroleum CHECK If BILLING ADDRESS ❑ <br /> FACILITY NAME Valley Pacific Petroleum Fresno Ave Cardlock <br /> SITE ADDRESS 1524 Fresno Ave Stockton 95206 <br /> Street Number Direction I Street Name city Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) 152 Frank West Circle <br /> Street Number Street Name <br /> CITY Stockton STATE CA Zip 95206 <br /> PHONE #1 EXT. APN # LAND USE APPLICATION # <br /> ( 209 ) 948 - 8412 <br /> PHONE #2 EXT. BOS DISTRICT LOCATION CODE <br /> ( 209 ) 993 - 8793 <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> Mike Eliason CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE # ' <br /> Valley Pacific Petroleum 209 993 - 8793 <br /> HOME or MAILING ADDRESS 152 Frank West Circle FAx # <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 <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 FEQEJL4L laws . <br /> APPLICANT ' S SIGNATURE : oe 99 DATE : 1 /21 /21 <br /> PROPERTY / BUSINESS OWNER OPERATOR / MANAGER ® OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT is not the BILLINGPARM 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. P <br /> TYPE OF SERVICE REQUESTED: l( S � C C, <br /> COMMENTS: <br /> JA <br /> N 2 1OA U <br /> y <br /> 2421 <br /> NET/ 0NMECOUN1" Y <br /> CEPA E <br /> I TM <br /> Nr <br /> J 7 <br /> ACCEPTED BY: ; t J12 <br /> \`/�� /Z GCJ EMPLOYEE #: DATE : <br /> ASSIGNED TO: f [ r J' EMPLOYEE M DATE: <br /> Date Service Completed (if already completed) : SERVICE CODE: P 1 E: <br /> Fee Amount: Amount Pal vC/ Payment Date <br /> Payment Type Invoice # I Check # — Received By: <br /> EHD 48-02-025 SR FORM (Golden Rod) <br /> REVISED 11 /17/2003 <br />