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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # SERVICE REQUEST # <br /> F1/1"GY� (2(O2�' � t I <br /> OWNER / OPERATOR <br /> United Pacific CHECK If BILLING ADDRESS <br /> FACILITY NAME United Pacific 76 Facility #5449 <br /> SITE ADDRESS 322 South Center Streetqlo� <br /> Stpckton <br /> Street Number Direction Street Name Cit 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 /> CA 9080 $ <br /> Long Beach <br /> PHONE #1 EXT, APN # LAND USE APPLICATION # <br /> ( 310 ) 323 -3992 2012 <br /> PHONE #2 EXT. BOS DISTRICT LOCATION CODE <br /> ( 310) 930-5415 <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR Matt Thomas CHECK if BILLING ADDRESS 13 <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 /> 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 /> APPLICANT' S SIGNATURE : � DATE ; 5 -6- 19 <br /> PROPERTY IBUSINESS OWNER ❑ OPERATOR I MANAGER ❑ OTHER AUTHORIZED AGENT Cj Manager GGRS <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 mimed to me or <br /> my representative . �g11/YYf, e ' <br /> TYPE OF SERVICE REQUESTED : <br /> i <br /> COMMENTS : <br /> UN 2 0 2419 <br /> SAN JOAQENVIFRONIN COUNTY <br /> HEALTF► pE ARTMENT <br /> ACCEPTED BY : S � �� EMPLOYEE #: /L� DATE : 1 911 q11 9 <br /> ASSIGNED TO : NJ 0 EMPLOYEE # : 67003 DATE : (Q l e111 <br /> I <br /> Date Service Completed ( if already completed) : SERVICE CODE : f rte' P / E :� 5Df� <br /> Fee Amount : lj r' p Amount Pai �y , Vo Payment Date l0 <br /> Payment Type Cf� Invoice # Check # 2777 1 Received By : <br /> EHD 48-02-025 SR FORM (Golden Rod ) <br /> 07/17/08 <br />