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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # SERVICE REQUEST # <br /> Fuel dispensing station �Oaa3 I 7 3/)L (P <br /> OWNER / OPERATOR B &W - Scott Castle (VP ) <br /> ti l CHECK If BILLING ADDRESs � <br /> FACILITY NAME <br /> Kwik Sery Lodi <br /> SITE ADDRESS W Kettieman Lane <br /> 420 Lodi <br /> Street Number 0 action SI oat Nan e C t zl Co 0 <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Strout amu <br /> CIN STATE ZIP <br /> PHONE #1 EXT. APN # LANDUSE APPLICATION # <br /> (209 ) 577-6000 <br /> PHONE #2 EXr, SOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> BZ Maintenance CHECK If BILLING ADDRESS ❑ <br /> BUSINESS NAME PHONE # ExT. <br /> BZ Maintenance 916 371 -2380 <br /> HOME or MAILING ADDRESS FAX # <br /> PO Box 933 ( ) <br /> CITY W Sacramento STATE CA . ZIP 95605 <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 : "Aktl� DATE # _ jLa. ce <br /> PROPERTY I 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 I r VIOd to me Or <br /> my representative. ~ r/I <br /> TYPE OF SERVICE REQUESTED : <br /> UST <br /> COMMENTS : rB <br /> Permit to replace 4 drop tubes and retest for overfill prevention inspection . SAN JOA <br /> V/R01V / <br /> OAI <br /> r . �fEA TH pASINLT y <br /> ANT <br /> ACCEPTED BY: \ EMPLOYEE #: DATE: <br /> ASSIGNED TO: t� EMPLOYEE #: DATE.: o�/� <br /> Date Service Completed (if already completed)a — SERVICECODE; P / E; ��� � <br /> Fee Amount ; (a� �D Amount Pa i S(OPayment Date <br /> Payment Type - Invoice # Check # 32 Received By : <br /> EHD 48-D2-025 SR FORM (Golden Rod) <br /> 07/17108 <br />