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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property d FACILITY ID # SERVICEREQUES34 <br /> Gas Station �/ I J , cl&s l <br /> OWNER / OPERATOR <br /> United Pacific #5447 Tom Robins CHECK if BILLING ADDRESS ❑ <br /> FACILITY NAME <br /> United Pacific #5447 <br /> SITE ADDRESS <br /> 1469 �at HammerStockton 95209 <br /> Street Number Drec on reef ame City Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> 4130 Cover Street <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> Long Beach CA 90808 <br /> PHONE 41 EXT. APN # LAND USE APPLICATION # <br /> ( 31W23-3992 <br /> PHONE #2 EXT• BOS DISTRICT LOCATION CODE <br /> ( 626}627-8316 <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 74S5838 <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 /> PPP <br /> APPLICANT'S SIGNATURE : 7'✓La�t- t�ir �� DATE: 3-1 -23 <br /> PROPERTY / BUSINESS OWNER ❑ OPERATOR I MANAGER ❑ OTHER AUTHORIZED AGENT ® Compliance Services Manager <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 linfoAnation <br /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the same time it Is provided �� <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: Q <br /> 1 <br /> hEFN R Q4J/ ? 023 <br /> A � TNC pgRT NTY <br /> NT <br /> So <br /> ACCEPTED BY: _ - G — EMPLOYEE #: DATE; <br /> ASSIGNED TO : CIVOI EMPLOYEE #: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: �90 2q0 PIE: � jG� <br /> Fee Amount: . / °O Amount Paid /E on Payment Date 411, 21 3 <br /> Payment Type Invoice # Check # l b� g Received By : <br /> EHD 48-02-025 SR FORM (Golden Rod) <br /> 07/17/08 <br />