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9 <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # SERVICE REQUEST # <br /> gas station ° <br /> OWNER / OPERATOR <br /> Muhammad BIIaI 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 Citv Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> same Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE #1 Exr. APN # LAND USE APPLICATION # <br /> ( 707 ) 486-8894 � r <br /> PHONE #2 Exr• BOS DISTRICT , Loc"' [ CODE <br /> �y <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK if BILLING ADDRESS <br /> Matt Thomas <br /> BUSINESS NAME PHONE # Exr' <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 /> •� <br /> PROPERTY / BUSINESS OWNEROPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT LT Manager CGRS , Inc <br /> IfAPPLiCANT is not the BILLINGPAR7Y 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 AM <br /> t f <br /> e it is <br /> provided to me or my representative . RECEIVED <br /> w <br /> TYPE OF SERVICE REQUESTED : z _ <br /> AUG 2 7 2021 <br /> COMMENTS : <br /> UST repair per plans & SOW SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENI <br /> ACCEPTED BY EMPLOYEE # : DATE > _f <br /> ' ' X c <br /> ASSIGNED TO EMPLOYEE # : DATE <br /> LAkP Date Service Completed (if already completed) . -� e SERVICE CODE , P / E <br /> Fee Amount . t I � , Amount Paid Payment Date <br /> Ar1 <br /> Pa Type Invoice # Check # Received B <br /> `v Y <br /> Payment Yp <br /> Y 7 <br /> ` ISR FORM Golden Rod <br /> EHD 4&02-025 a ( ) <br /> REVISED 11 /17/20031 <br />