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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # SERVICE REQUEST # <br /> gas station SP ® ®U4 l� <br /> OWNER / OPERATOR <br /> Muhammad Bilal CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> Chevron Gas Station <br /> SITE ADDRESS 10878 North Highway 99 Stockton 95212 <br /> Street Number Direction Street Name Cit Zi Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> same Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE #1 ExT• APN # LAND USE APPLICATION # <br /> ( 707 ) 486-8894 <br /> PHONE #2 ExT BOS DISTRICT ` LOC/yTJQI� CODE <br /> ( ) fVl ��V�V <br /> CONTRACTOR / SERVICE REQUESTOR <br /> R:EQUESTOR <br /> Matt Thomas CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE # ExT, <br /> CGRS Inc. ( 916 991 - 1100 <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 <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 /> APPLICANT ' S SIGNATURE : DATE & 8-26-21 <br /> PROPERTY / BUSINESS OWNER ❑ OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT LT Manager CGRS , Inc. <br /> If APPLICANT is not the BILLINGPART3; 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 <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 and at fhv, to e it is <br /> provided to me or my representative . PAM IV I <br /> TYPE OF SERVICE REQUESTED : U SrRV fwm <br /> COMMENTS : <br /> UST repair per plans & SOW SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPART MEN1 <br /> ACCEPTED BY: I <br /> V .� EMPLOYEE # : DATE :t�Qm 24 Z <br /> ASSIGNED TO : � f EMPLOYEE # : DATE : 2 <br /> i <br /> Date Service Completed (if already completed SERVICE CODE: 2� B PIE : <br /> Fee Amount : ffXJ Amount Paid Payment Date O 2 z l <br /> Payment Type G QA.` Invoice # Check # Received By: <br /> EHD48-02-025 � 5 ( ,,,, , ly, , 13u gSR4RM (Iden Rod) <br /> REVISED 11 /17/2003 <br />