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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 and convenience store H `I Qolxv � <br /> OWNER/OPERATOR <br /> Apro, LLC CHECK if BILLING ADDRESS <br /> FACILITY NAME Rocket#5267 <br /> SITE ADDRESS West Lathrop Rd Manteca 95336 <br /> 1137 Street Number Direction Street Name City Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) 4130 Cover St <br /> Sheet Number Street Name <br /> CITY Long Beach STATE CA ZIP 90808 <br /> PHONE#1 ExT. APN# LAND USE APPLICATION# <br /> (310) 323-3992 <br /> PHONE#2 ExT. EMAIL permits@unitedpacific.com BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR Apro, LLC CHECK If BILLING ADDRESS <br /> BUSINESS NAME Rocket#5247P. <br /> PHONE# ExT. <br /> h <br /> HOME Or MAILING ADDRESS 21�q �p 3 Lt 131 ,paw 1 G Co-M FAx# <br /> r Y` ( ) <br /> CITY STATE ZIP EMAIL <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 activity <br /> 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 AL laws. <br /> APPLICANT'S SIGNATURE: DATE: '/ -2-3 <br /> PROPERTY I BUSINESS OWNER❑ OPERATOR I MANAGER ❑ OTHER AUTHORIZED AGENT © Director of Regulatory Affairs <br /> If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required Tir1e <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable,I,the owner or operator of the property located at the above site <br /> address,hereby authorize the release of any and all results,geotechnical data and/or environmental/site assessment information to the <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as Soon as It is available and at the Same time it IS ovided to me or my <br /> representative. �J <br /> IV <br /> TYPE OF SERVICE REQUESTED: ��r. (% -> E �l <br /> Vr- <br /> COMMENTS: MA V <br /> /i 1SAN j0A 1023 <br /> NiMA NHE -I NEWTy <br /> EPARTMENT <br /> ACCEPTED BY: C��r �� EMPLOYEE#: DATE: Z_10 <br /> ASSIGNED TO: EMPLOYEE#: DATE: S—��t S <br /> Date Service Completed (if already completed): SERVICE CODE: P 1 E: 166.2- <br /> Fee Amount: Amount Paid /6r jVD Payment Date5I0 13 <br /> Payment Type Lso_ Invoice# Received By: <br /> EFID 48-02-025 SR FORM(Golden Rod) <br /> 03/22/23 <br /> 5 <br />