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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />SERRVI�CE REQUEST # <br />RETAIL GASOLINE DISPENSING <br />FACILITY <br />PHONE# <br />�� ODIC 7 <br />Z <br />-. <br />'Sp Otr,"�Ll <br />OWNER / OPERATOR <br />R ae la <br />HOME or MAILING ADDRESS 30 MAIN AVE SUITE #5, SACRAMENTO, <br />CA. 95838 <br />FAx# <br />EMPLOYEE <br />CHECK If BILLING ADDRESS❑ <br />CHEVRON <br />PRODUCTS COMPANY <br />CITY SACRAMENTO <br />FACILITY NAME <br />ZIP 95838 <br />ASSIGNED TO: -/ <br />CHEVRON #94275 <br />EMPLOYEE <br />#: <br />DATE: '�j /0 <br />SITE ADDRESS 2905 <br />W <br />WEST BENJAMIN <br />HOLT DR <br />C)v <br />Fee Amount: 0O <br />STOCKTON <br />7952707 <br />Street Number <br />Direction <br />Payment Type <br />Street Name <br />Cit <br />Code <br />HOME or MAILING ADDRESS (If Different from <br />Site Address) <br />30 MAIN AVE <br />SUITE #5 <br />Street Number <br />Street Name <br />CITY <br />STATE CA ZIP 95838 <br />SACRAMENTO <br />PHONE #1 EXT* <br />N# <br />LAND USE APPLICATION # <br />( 916) 646-9680 <br />PHONE #2 EXT, <br />( ) <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR /SERVICE REQUESTOR <br />REQUESTOR <br />BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent pf,came, <br />DYLAN SMITH <br />CHECK if BILLING ADDRESS <br />BUSINESS NAME WAYNE PERRY INC <br />OVATION 2 DISPENSERS (LIKE FOR LIKE), REPLACE <br />PHONE# <br />EXT, <br />646-9680 <br />SAME MODEL, PULL NEW POWER, DATA, AND <br />CAT6 CABLE <br />916 <br />R ae la <br />HOME or MAILING ADDRESS 30 MAIN AVE SUITE #5, SACRAMENTO, <br />CA. 95838 <br />FAx# <br />EMPLOYEE <br />(916)646-9683 <br />CITY SACRAMENTO <br />STATE CA <br />ZIP 95838 <br />acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly Charges associated with thl r�6JJ <br />activity will be billed to me or my business as identified on this form. l`CC,�/I�'N,► <br />also certify that I have prepared this application and that the work to be performed will be done in accordance with all $AN JOAQu1rJ�' �D <br />COUNTY Ordinance Codes, Standards, STATE and FEDERAL laws. AN i O <br />APPLICANT'S SIGNATURE: T�cZ <br />�-ry �`�[� DATE: 5/8/2023 SAS ;!�An,,,.v !(/?,� <br />PROPERTY/ BUSINESS OWNER ❑ OPERATOR? MANAGER ❑ OTHER AUTHORIZED AGENT iia PERMIT TEt'64CTy ONIi�v <br />EcOvNTY <br />If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required Title rMENT <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 t0 me or <br />my representative. <br />TYPE OF SERVICE REQUESTED: DISPENSER <br />REPLACEMENT <br />COMMENTS: <br />REMOVE DRESSER WAYNE OVATION DISPENSERS AND INSTALL NEW DRESSER WAYNE <br />OVATION 2 DISPENSERS (LIKE FOR LIKE), REPLACE <br />SUPREME <br />TURBINE WITH NEW OF <br />SAME MODEL, PULL NEW POWER, DATA, AND <br />CAT6 CABLE <br />TO ALL DISPENSERS <br />R ae la <br />ACCEPTED BY: ���� G. <br />EMPLOYEE <br />DATE: tV430 23 <br />ASSIGNED TO: -/ <br />EMPLOYEE <br />#: <br />DATE: '�j /0 <br />Date Service Completed (if already completed): <br />412 <br />SERVICE CODE: <br />PIE: Z5oE <br />C)v <br />Fee Amount: 0O <br />Amount Pai <br />9 vo <br />Payment Date 312, <br />Payment Type <br />Invoice # <br />Check # <br />16p z 58Y I 7 <br />Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />07/17/08 <br />