Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITYID # SERVICE REQUEST # <br /> Gas station <br /> OWNER / OPERATOR CHECK if BILLING ADDRESS [] <br /> Chevron Products Company <br /> FACILITY NAME <br /> Chevron Stations Inc . #94275 <br /> SITE ADDRESS <br /> 2905 Street Number DirWectiest Benjamin Holt Dr. Street Name Stockton , CA 95207 <br /> on Cit Zi 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 /> ( <br /> PHONE #2 EXT. BOS DISTRICT LOCATION CODE <br /> ( <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> Monica Molinar CHECK if BILLING ADDRESS ® <br /> BUSINESS NAME PHONE # ExT, <br /> West Wind Consulting , Inc . 714 745-0415 <br /> HOME or MAILING ADDRESS FAx # <br /> 3334 E . Coast Hwy . , Suite 550 ( ) <br /> CITY STATE ZIP <br /> Corona Del Mar, CA 92625 <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 : 714 DATE : 0727 . 22 <br /> PROPERTY / BUSINESS OWNER ❑ OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT ® Project Manager <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 provide !ne or <br /> my representative . Y <br /> TYPE OF SERVICE REQUESTED : UST le it �"FJ 7 �� <br /> COMMENTS : A O o <br /> Remove and replace 91 supreme unleaded overfill prevention flapper valve with new SqN � , 20 <br /> OPW 71SO-410C . yEq� tiooNMV <br /> FpgRTr� c. � ) <br /> COOV <br /> ACCEPTED BY: / j y�� \ / EMPLOYEE # : DATE: <br /> ASSIGNED TO : 1 / •�e h EMPLOYEE # : DATE: ) 2 2z <br /> Date Service Completed (if already completed) : - SERVICE CODE : Jq ;�> q S' P / E: <br /> Fee Amount: , iii ° Amount Paid ��� D� Payment Date g zZ <br /> Payment Type AAII Invoice # Check # 76 53 ?0 Received By: <br /> 2h( 117 7 <br /> EHD 48-02-025 SR FORM (Golden Rod) <br /> 07/ 17/08 <br />