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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> SERVICE <br /> Type of Business or Property FACILITY ID # REQUEST <br /> GDF GDF . n <br /> fu <br /> OWNER <br /> f� w <br /> OWNER / OPERATOR r <br /> First Evergreen Oil Corp , DBA Tiwana Gas and Food CHECK if BILLING ADDRESS ❑ <br /> FACILITY NAME Tiwana Gas and Food <br /> SITE ADDRESS 1210 E Hammer Lane Stockton 95210 <br /> Street Number Direction I Street Name cityZi Codo <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE #1 EXT. IN # LAND USE APPLICATION # <br /> ( 209) 715-0124 <br /> PHONE #2 EXT• BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR Janelle Dockham CHECK if BILLING ADDRESS ® <br /> BUSINESS NAME NweStco , LLC PHONE ft EXT. <br /> ( 661 )-631 - 3870 <br /> HOME or MAILING ADDRESS FAX # <br /> 2209 Zeus Court ( 661 ) 587-9758 <br /> CITY Bakersfield STATE CA ZIP 93308 <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 : Q� � L cle,iDATE : 8/ 15/2022 <br /> PROPERTY / BUSINESS OWNER ❑ OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT ® Permit Clerk <br /> If APPLICANT Is not the BILLING PARTY, proof Of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION : When applicable , 1 , the owner or operator of thegroheWSDrOVJid' ed <br /> t the above <br /> site address , hereby authorize the release of any and all results , geotechnical data and/or environmental/.ct information <br /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same to me or <br /> my representative . MG ? <br /> TYPE OF SERVICE REQUESTED : coutWl <br /> COMMENTS : yt rj4vi oe�na11*% N1 <br /> Cut and break out 3 ' 3 ' area of concrete in front of each UDC . Expose piping to replace flexlin <br /> on bottom . Retest after repairs . We will start with the (2 ) closest dispensers to tank pit , If we do not <br /> locate leak at these (2 ) we will move on to farthest dispensers . <br /> ACCEPTED BY : EMPLOYEE M DATE: <br /> ASSIGNED TO : EMPLOYEE #: DATE: o / / „ <br /> Date Service Completed (if already completed) : SERVICE CODE : M,! fid? e P 1 E: I ao <br /> Fee Amount: Amount Paid Payment Date <br /> Payment Type �, Invoice # ck # ' ` � '� Received By: <br /> EHD48-02-025 � ` � Z <br /> SR FORM (Golden Rod ) <br /> 07/17/08 <br />