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L t <br /> SAN JOAQUI COUNTY ENVIRONMENTAL HEALTH R-PARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property ] FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR l/ <br /> United Pacific CHECK If BILLING ADDRESS <br /> FACILITY NAME United Pacific 76 Facility#5447 <br /> SITE ADDRESS 1469 East Hammer Lane <br /> (� <br /> St ckton <br /> Street Number Direction Street Name Oit Zip Code <br /> HOME or MAILING ADDRESS (if Different from Site Address) 4130 Cover Street <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> Long Beach CA 90808 <br /> PHONE#1 ExT. APN# LAND USE APPLICATION# <br /> (310)323-3992 2012 0? bb <br /> PHONE#2 ExT. BOS DISTRICT LOCATION CODE <br /> ( 310) 930-5415 O <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> Matt Thomas CHECK If BILLING ADDRESSM <br /> BUSINESS NAME PHONE# ExT. <br /> CGRS, Inc. 626 627-8316 <br /> HOME or MAILING ADDRESS FAX# <br /> 5444 Dry Creek Road ( ) <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 /> 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: .�-I;&M zdd DATE: 9-14-18 <br /> PROPERTY/BUSINESS OWNER 11 OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT R 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 /> t0 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: Y <br /> COMMENTS: & ILIZUE1VED <br /> SEP 21 ?018 <br /> ���0/N COUNTY HFALThI p pM'ENTq� n' <br /> ACCEPTED BY: � EMPLOYEE#: DATE:Yjt 1 <br /> ASSIGNED TO: l�Ai:Jr/1 W EMPLOYEE#: 61001 DATE: et , J6 <br /> Date Service Completed (if already completed): SERVICE CODE: Q PIE: �� <br /> Fee Amount: Amount PaiA-TLZ 60 Payment Date <br /> Payment Type Invoice# Ch k# �3�q7 Received By: ,Zr " <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />