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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # A SERVICE REQUEST # <br /> Fuel Station Do vc) / c:) nc53q <br /> OWNER / OPERATOR <br /> Vanessa Cortez CHECK if BILLING ADDRESS <br /> FACILITY NAME J&L Market <br /> SITE ADDRESS0812 South El Dorado Street French Camp 9 1 <br /> Street Number Direction Street Name City Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE #1 EXT. APN # LAND USE APPLICATION # <br /> ( ) <br /> PHONE #2 EXT, BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> Matt Thomas CHECK If BILLING ADDRESSE] <br /> BUSINESS NAME CGRS, Inc PHONE # ExT. <br /> 916 991 - 1100 <br /> HOME or MAILING ADDRESS FAX # <br /> 5444 Dry Creek Rd. ( ) <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 : DATE : 04/ 14/22 <br /> PROPERTY / BUSINESS OWNER ❑ OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT © Manager <br /> If APPLICANT is not the BILLING PARTY, proof of authorization to Sign IS required Title <br /> AUTHORIZATION TO RELEASE INFORMATION : When applicable , 1 , the owner or operator of the property to the above <br /> site address , hereby authorize the release of any and all results , geotechnical data and/or environmental/site_ DQA nformation <br /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the same tlti t0 vl ed to me or <br /> my representative . r <br /> TYPE OF SERVICE REQUESTED : uv / r� p COUNTY <br /> COMMENTS : <br /> � �/ � O� t��CJs�'ci� V � C HEAL HUEPpRT1,1EN1 <br /> ACCEPTED BY : _ aw EMPLOYEE # : DATE: , 7 <br /> ASSIGNED TO : EMPLOYEE # : DATE: <br /> Date Service Completed ( if already completed) : SERVICE CODE: / �� ��q Pi E : <br /> Fee Amount: yGJ- za Amount Paid Payment Date <br /> Payment Type V Invoice # C�eck / 3 Received By : <br /> EHD 48-02-025 SR FORM (Golden Rod) <br /> 07/ 17/08 <br />