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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # �,�ERV REQUrNON &0 �T� <br /> OWNER / OPERATOR <br /> United Pacific CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> United Pacific #5446 <br /> SITE ADDRESS 1403 Country Club Road Stockton 95204 <br /> Street Number Direction I Street Name Citv Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> 4130 street Number Cover Stereet Street Name <br /> CITY STATE ZIP <br /> Lonfg Beach CA 90808 <br /> PHONE #1 ExT• APN # LAND USE APPLICATION # <br /> ( 310) 323-3992 x2012 <br /> PHONE #2 Exr• BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> Matt Thomas CHECK if BILLING ADDRESS LA <br /> BUSINESS NAME PHONE # ExT• <br /> CGRS , Inc, ( 916 ) 991 - 1100 <br /> HOME or MAILING ADDRESS 5444 Dry Creek Road FAX # <br /> ( ) <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 : MAof f 'j'h&Kt4y DATE : 12/28/2022 <br /> PROPERTY / BUSINESS OWNER ❑ OPERATOR / MANAGER ❑ OTHERAUTHORIZED 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 <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 , fl A <br /> TYPE OF SERVICE REQUESTED : U S Fe av � � C r 7 /� (�1Z��1 N7"7q t <br /> COMMENTS : / . � ` U O � OEC[ � rj c 3 0 Z z <br /> HEN HgoNMENT NTy <br /> DEpARTIV] NT <br /> ACCEPTED BY: �. n � /C� '� 1/ EMPLOYEE # : DATE : 12 ,2� : �� <br /> ASSIGNED TO : C /f'�\// nC EMPLOYEE # : DATE : r Z �+ 2 � <br /> Date Service Completed (if already completed ) : SERVICE CODE : ! e7eyl P I E : 2 C y - <br /> Fee Amount : / �& L' Amount Paid l�/ z �7 Payment Date 1 22- <br /> Payment TypeInvoice # Check # /S 7� Received By: <br /> 27 I <br /> EHD 48-02-025 SR FORM (Golden Rod ) <br /> REVISED 11 / 17/2003 <br />