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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 <br /> F14-0001141wl400p <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 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 EXT• APN # LAND USE APPLICATION # <br /> ( 707 ) 486 -8894 <br /> PHONE #2 Ex-r. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <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 . . 5- 10-22 <br /> PROPERTY / BUSINESS OWNER ❑ OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT LT Manager CGRS , Inc. <br /> If APPLICANT is not theBTLLTNGPARTI; 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 the same time it is <br /> provided to me or my representative . M <br /> TYPE OF SERVICE REQUESTED : � S E � �� ` U 1 MEW <br /> COMMENTS : V <br /> Relocate drain valve/test port to the lowest quadrant of the piping A , AV <br /> MAY I � zozz <br /> NE N Hg0NMECOON . <br /> DEpAR T,q , <br /> ACCEPTED BY: ��/ EMPLOYEE # : DATE : j9/ 04Z <br /> ASSIGNED TO : /rj p �a�Q EMPLOYEE # : DATE : <br /> Date Service Completed (if already completed) : SERVICE CODE: /ge � 2-GI e P / E :2�no <br /> Fee Amount : f�j 2 0 0 Amount P /� 4 v � Payment Date <br /> < <br /> Payment Type ' Invoice # Check # f TJ Received By : <br /> EHD 48-02-025 SR FORM (Golden Rod ) <br /> REVISED 11 / 17/2003 <br />