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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 �'� <br /> 000 1 0 `j 009 j675 <br /> OWNER / OPERATOR <br /> CHECK If BILLING ADDRESS <br /> First Evergreen Oil Corporation DBA Tiwana Gas <br /> FACILITY NAME <br /> Valero Hammer Lane <br /> 95210 <br /> SITE ADDRESS E <br /> Stockton <br /> 1210 Hammer Lane <br /> Street Number Direction Street Name Citv 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 /> ( 209 ) 715-0124 <br /> PHONE #2 EXT, BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> Janelle Dockham CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE # EXT, <br /> Confidence UST Services 661 631 -3870 <br /> HOME or MAILING ADDRESS FAX # <br /> 16250 Meacham Road ( 661 ) 587-9758 <br /> CITY STATE cA ZIP 93314 <br /> Bakersfield <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 laaw//s . <br /> APPLICANT' S SIGNATURE : 0 � �BCLlLy� DATE : 05/04/2021 <br /> PROPERTY / BUSINESS OWNER ❑ I OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT L] Permit Clerk <br /> If APPLICANT Is not the BILLING PARTY, proof of authorization to sigh 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 to me or <br /> my representative . ,Q <br /> TYPE OF SERVICE REQUESTED : L4 12h ' 1 <br /> COMMENTS: <br /> sqN '�qY �] O <br /> . h'F ���R�Fp��N co Q2 <br /> q�NT�N <br /> ACCEPTED BY: �V/J /�>j j EMPLOYEE # : DATE: <br /> ASSIGNED TO : S (,u/ / , w v`% �/ n rriv p EMPLOYEE #: DATE : 5/44:::7/ <br /> ` ' <br /> Date Service Completed ( if already completed) : — SERVICE CODE : + �, PIE : � C <br /> Fee Amount: 44 L �`' Amount Palta �� Payment Date O <br /> t <br /> Payment Type , <br /> �� Invoice # Check # 2 , lg -n Received By : <br /> EHD 48-02-025 I SR FORM (Golden Rod) <br /> 07/17/08 <br />