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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 "" " 103 Z S12oc) 5 019 v) <br /> OWNER / OPERATOR <br /> Chevron USA Products Company CHECK if BILLINGADDRESSE] <br /> FACILITY NAME Chevron #94275 <br /> SITE ADDRESS 2905 W Benjamin Holt Drive Stockton F95207 <br /> Street Number Direction Street Name Cit i 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 Wayne Perry Inc . CHECK If BILLING ADDRESS <br /> BUSINESS NAME Wayne Perry Inc . PHONE # ExT, <br /> 916-646-9680 <br /> HOME or MAILING ADDRESS 30 Main Ave , Suite 5 , Sacramento , CA 95838 FAx # <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 <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 FEDERAL laws , <br /> APPLICANT ' S SIGNATURE : � ��� D �B'/NQ&& DATE : 10-31 -2022 <br /> PROPERTY / BUSINESS OWNER ❑ OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT ® Contractor Project Manager <br /> IfAPPLICANT 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 <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 s�e time it is <br /> provided to me or my representative . .q Y <br /> TYPE OF SERVICE REQUESTED : <br /> COMMENTS : Off/ <br /> s F� JO 1 43 269 <br /> yFq Ty �Ep4 OO <br /> r RTMFNT <br /> ACCEPTED BY: _ /J �/Q (s-� EMPLOYEE # : DATE : / Z ZZ <br /> ASSIGNED TO : <br /> oneMa <br /> /� �`,� � EMPLOYEE # : DATE : <br /> Date Service Completed ( if already completed) : — SERVICE CODE : AfI <br /> � 2a r P I E : <br /> Fee Amount: Amount Paidg• Payment Date <br /> Payment Type Invoice # Check # I522� SS3 (�o Received By : <br /> EHD 48-02-025 SR FORM (Golden Rod) <br /> REVISED 11 /17/2003 <br />