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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # SERVICE REQ Tff <br /> RETAIL GAS STATION A a 7o O D c 0 <br /> OWNER / OPERATOR <br /> APRO , LLC , CHECK If BILLING ADDRESS <br /> FACILITY NAME UNITED PACIFIC #544 <br /> 17 <br /> SITE ADDRESS 1469 E Hammer Lane STOCKTON 95210 <br /> Street Number Direction Street Name city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> SAME AS Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE #1 ExT• APN # LAND USE APPLICATION # <br /> ( 209 ) 943-2082 <br /> PHONE #2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> ROSS MCLAREN CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE # ExT, <br /> RM FUEL SYSTEMS 805 710-2006 <br /> HOME or MAILING ADDRESS FAX # <br /> 28030 VALCOUR DRIVE ( ) <br /> CITY CANYON COUNTRY STATE CA ZIP 91387 <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 : /8�&dod DATE : 05- 15-2021 <br /> PROPERTY / BUSINESS OWNER ❑ OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT ® CONTRACTOR <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 . go <br /> TYPE OF SERVICE REQUESTED : DISPENSER REPLACEMENT Y <br /> COMMENTS : REMOVE EXISTING DISPENSERS AND INSTALL NEW GILBARCO ENCORE 700S DISPENSERS, • / <br /> s / 4? ? / <br /> N q N�R Q�/NO <br /> G Tjy �pq v Ou� Y <br /> ACCEPTED BY: �; �� % �. ,A/y EMPLOYEE M DATE: 9 . l .gI/ / <br /> ASSIGNED TO : ( wl J " — EMPLOYEE M DATE: /' _ 7 wCl ' t?�/ <br /> Date Service Completed ( if already completed ) : SERVICE CODE : PIE : Z 2 <br /> Fee Amount: (,�G� /„ dv Amount PaidlSrP , � (J Payment Date S / 7 l <br /> Payment Type `p�v ��- Invoice # Check # 1 �- 4 g5g Receivd By : <br /> EHD 48-02-025 SR FORM (Golden Rod) <br /> 07/17/08 <br />