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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY 10 # SERVICE REQUEST # <br /> Gas Sation Q S I VT <br /> OWNER / OPERATOR <br /> United Pacific CHECK If BILLINGADDRESSE] <br /> FACILITY NAME United Pacific 76 Facility #5447 <br /> SITE ADDRESS 1469 1 E Hammer Lane <br /> Stpckton 95210 <br /> Street Number Direction Cit Zip Code <br /> HOME or MAILING ADDRESS ( If Different from Site Address) 4130 Cover Street <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> Long Beach CA 90808 <br /> PHONE #t EXT* APN # LAND USE APPLICATION # <br /> ( 310 ) 323 - 3992 2012 1490611 <br /> PHONE #2 EXT. BOS DISTRICTF01 - STKN <br /> OCATION CODE <br /> ( 310) 930 - 5415 001 <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS X <br /> Matt Thomas <br /> BUSINESS NAME PHONE # EXT. <br /> CGRS , Inc . 626 627-8316 <br /> HOME or MAILING ADDRESS FAX # <br /> 5444 Dry Creek Road ( 916 ) 991 - 1177 <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 /> 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 /> AFFI- IC�, I\II rrfrf I/, i t1F (= : DATE * 08 / 12/ 19 <br /> PROPERTY / BUSINESS OWNER ❑ OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT 13 Manager CGRS <br /> If APPLICANT is not the BILLING PARTY, proof of authorization to sign Is required Tit /pA <br /> AUTHORIZATION TO RELEASE INFORMATION : When applicable , I , the owner or operator of the property 10c <br /> site address , hereby authorize the release of any and all results , geotechnical data and/or environmental/site asses ,E11 <br /> pff <br /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the same time It Is provided to irrundr <br /> my representative . AUG <br /> TYPE OF SERVICE REQUESTED : 4r/ � . Sq� JOgQUt <br /> COMMENTS : Scope of Work: HEgLTH NMENIq! <br /> Scope of Work: �EpMTMENT <br /> • Saw cut, demo , remove and replace 87 , 89 fill/ spill & vapor buckets and diesel fill bucket, double wall OPW Edge <br /> buckets , testable 71SO - 41OCT OPW shut off valves . <br /> * Place concrete , and retest spill buckets & OPI inspections . <br /> ACCEPTED BY : V EMPLOYEE #: DATE : Z2 / <br /> ASSIGNED TO : ,l EMPLOYEE M DATE : <br /> Date Service Completed (if already completed ) : SERVICE CODE : qF P <br /> Fee Amount : "? Amount Paid �S ;e �� Payment Date 1 w� <br /> Payment Type Invoice # Check # 3 Received By : <br /> EHD 48-02-025 SR FORM (Golden Rod) <br /> 07/ 17/08 <br />