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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # F2,ERVICE REQUEST # <br /> Commercial Fueling Cardlock � ' ( V) 07Z V o ® \ ts�g q <br /> OWNER / OPERATOR <br /> CHECK If BILLING ADDRESS <br /> Valley Pacific Petroleum <br /> FACILITY NAME Valley Pacific Fresno Ave Cardlock <br /> SITE ADDRESS 1524 Fresno Ave Stockton 95206 <br /> Street Number Direction I Street Name city Zip Code <br /> HOME or MAILING ADDRESS ( If Different from Site Address) 152 Frank West Circle <br /> Street Number Street Name <br /> CITY Stockton STATE CA z"95206 <br /> PHONE #1 EXT, APN # LAND USE APPLICATION # <br /> (209 ) 993 -8793 <br /> PHONE #2 EXT, BOS DISTRICTLOCATION CODE <br /> (209 ) 948 -9412 <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR Mike Eliason <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE # EXT. <br /> Valley Pacific Petroleum (209 ) 993 - 8793 <br /> HOME or MAILING ADDRESS 152 Frank West Circle , Stockton , 95206 FAX # <br /> CITY STATE ZIP <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 F R <br /> 'AL laws . <br /> fit P P I_ IcA I rT r lG f\iAT [JR [':: : DATE 10/ 10/2022 <br /> PROPERTY .1 B4JSINESS OWNER n( OPERATOR / MANAGER © OTHER AUTHORIZED AGENT ❑ <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 /> t0 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 . <br /> 0 OWN <br /> TYPE OF SERVICE REQUESTED : PMME 1% <br /> COMMENTS: <br /> OCT 1 1 2022 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY : EMPLOYEE M EDAT <br /> e � <br /> ASSIGNED TO : EMPLOYEE # : <br /> Date Service Completed ( if already Completed ) : — SERVICE CODE : , L,'V S ' j - ( ' P I E : <br /> Fee Amount : � � Amount Paid /(l Payment Date ' u tj 2,0 2 <br /> Payment Type Vd Invoice # Check # � 2 ( 1 S Z Received By : <br /> EHD 48-02-025 SR FORM ( Golden Rod ) <br /> 07/ 17/08 <br />