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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # SERVICE REQUEST # <br /> Gas Dispensing Facility /71a 0 � �/ � G a oos�f i ,` l <br /> OWNER / OPERATOR J F� 1 <br /> Chevron USA Products Company CHECK if BILLING ADDRESS <br /> FACILITY NAME Chevron 494275 <br /> SITE ADDRESS 2905 W Benjamin Holt Drive Stockton 95207 <br /> Street Number Direction I Street Name city Zip Code <br /> HOME or MAILING ADDRESS ( If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE #1 ExT• APN # LAND USE APPLICATION # <br /> 00 0C)OO <br /> PHONE #2 EXT, BOS DISTRICT _Z LOC 1 i CODE <br /> DO U <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR Wayne Perry Inc CHECKifBILLING ADDRESSH <br /> BUSINESS NAME PHONE ExT. <br /> Wayne Perry Inc ) 916 - 646 - 9680 <br /> HOME or MAILING ADDRESS 30 Main Ave Suite 5 FAX # <br /> ( ) 916 - 646 - 9683 <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 laws . / <br /> APPLICANT' S SIGNATURE : DATE : 03 / 09 / 2021 <br /> PROPERTY / BUSINESS OWNER ❑ OPERATOR / 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 provided t0 me Or <br /> my representative . P <br /> 04 A <br /> TYPE OF SERVICE REQUESTED : j / 6P11 <br /> NT <br /> COMMENTS : IA O <br /> ' 'SAN ✓O R G 2021 <br /> yFA Ty D4��NoUN �f' <br /> ARTME <br /> ACCEPTED BY: �" C �J�� /'7f EMPLOYEE # : DATE: <br /> ASSIGNED TO : V L \C �(r / `t/) / (��/ C/�J iev EMPLOYEE # : DATE : <br /> Date Service Completed ( if already'completed) : v� SERVICE CODE : P I E : 233C1 ," <br /> Fee Amount : � lb� �'U Amount Pai Payment[ Date <br /> Payment Type Invoice # Check # 853v Recei ed By : <br /> EHD 48-02-025 SR FORM (Golden Rod) <br /> 07/ 17/08 <br />