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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # S SERVICE <br /> � EQUEST # <br /> Gas Station FA0001570 f cogu q <br /> OWNER / OPERATOR <br /> CHECK If BILLING ADDRESS <br /> United Pacific <br /> FACILITY NAME <br /> United Pacific 76 Facili # 5447 <br /> SITE ADDRESS 1469 E HAMMER LANE STOCKTON 95210 <br /> Street Number Direction Street Name city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 4130 COVER STREET <br /> Street Number Street Name <br /> CITY LONG BEACH STATE CA ZIP <br /> 90808 <br /> PHONE #'I EXT. APN # LAND USE APPLICATION # <br /> (310 ) 323 - 3992 2012 1490611 <br /> PHONE #2 EXT, BOS DISTRICT 7 LOCATION CODE <br /> ( 310 ) 930 - 5415 001 O1 - STKN <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> MATT THOMAS CHECK If BILLING ADDRESS X <br /> BUSINESS NAME PHONE # EXT, <br /> CGRS , INC 626 627 - 8316 <br /> HOME Or MAILING ADDRESS FAX # <br /> 5444 DRY CREEK ROAD ( 916 ) 911 - 1177 <br /> CITY SACRAMENTO STATE CA ZIP 95838 <br /> BILLING ACKNOWLEDGEMENT: 1, 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 /> 9 / 15 /20 <br /> APPLICANT' S SIGNATURE : �` i�/ DATE :: <br /> PROPERTY / BUSINESS OWNER ❑ OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT M MANAGER - CGRS <br /> IfAPPLICANT 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 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 an t the same time it is <br /> provided to me or my representative . PAY <br /> rTt <br /> TYPE OF SERVICE REQUESTED : �� S � � � �� t � e/ V <br /> COMMENTS : SEP 3 0 2010 <br /> SAN JOAQUI <br /> HEALTIq pE. COUNTY <br /> � (��n p ENT <br /> ACCEPTED BY : V Q //� ' EMPLOYEE # : DATE : ( 3U4,0 <br /> ASSIGNED TO : vAIS <br /> 0 EMPLOYEE # : I DATE : <br /> Date Service Completed ( if already completed) :'- SERVICE CODE : <br /> completed) :'- 1q- <br /> Date P I E : 2zo 4? <br /> Fee Amount: / cc) Amount P �S6 , 0U Payment Date [ 30 <br /> Payment Type 6eeJ; 7 Invoice # Check # l 1 f d�7 � Receiv d By : <br /> EHD 48-02-025 SR FORM (Golden Rod) <br /> REVISED 11 /17/2003 <br />