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CF <br /> J i <br /> MA , \ ' 1 ZOZOSAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # SERVICE REQUEST( # <br /> whare house ,�1 t' <br /> OWNER / OPERATOR <br /> CHECK If BILLING ADDRESS ® <br /> // XO ('' / ft <br /> FACILITY NAME <br /> SITE ADDRESS ( / 1624 TATrC Stpckton � z�Cod� <br /> Street Number Direction <br /> HOME Or MAILING ADDRESS (If Different from Site Address) $—Sp O Equity Drive <br /> Street Number Street Name <br /> CITY STATE zip <br /> Reno Alevim ISNa" <br /> PHONE #t ExT. API # LAND USE APPLICATION # <br /> c 7�s►� 43 �� - gag _ AP <br /> �0 (J <br /> PHONE #T ExT. L / BOS DISTRICT LOC TION CODE �® <br /> ((1,16 ) �i .1- 7 � g 3/ .6 .a� �l / /7O .y, �ANJO <br /> Vi CO <br /> CONTRACTOR / SERVICE REQUESTOR HEALTy D� N1E TM NT <br /> RECIUESTOR CHECK if BILLING ADDRESS <br /> Matt Thomas <br /> BUSINESS NAME PHONE # EXT, <br /> CGRS , Inc . 626 627-8316 <br /> HOME Or MAILING ADDRESS FAX # <br /> 5444 Dry Creek Road ( 916 ) 991 - 1177 <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 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 /> DATE : 3 -34 - �L0 <br /> PROPERTY / BUSINESS OWNER ❑ OPERATOR / MA AGER ❑ OTHER AUTHORIZED AGENT Manager CGRS <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 /> to 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 /> TYPE OF SERVICE REQUESTED : <br /> COMMENTS: Scope of Work: <br /> oRemove one ( 1 ) 10 , 000 gallon UST , provide soil sampling, and back fill per attached scope of work <br /> ACCEPTED BY : Autll EMPLOYEE M DATE: <br /> ASSIGNED TO : ` U EMPLOYEE M (J Z DATE : <br /> Date Service Completed (if already completed ) : SERVICE CODE: P / E: a (� <br /> Fee Amount : y Amount Pai � �� Payment Date 3 <br /> Payment Type W� I <br /> Invoice # Check # f 07 21)P70 2 Received By : <br /> EHD 48-02-025 SR FORM (Golden Rod ) <br /> 07/17/08 <br />