Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # RSERVICE <br /> , 7�R-EQUEST # <br /> ride <br /> Gas Sation � �� r �00 I J II <br /> OWNER i OPERATOR CHECK If BILLING ADDRESS ❑ <br /> United Pacific <br /> FACILITY NAME United Pacific 76 Facility #5446 <br /> SITE ADDRESS 1403 County Club Rd . Stpckton ?520 �- <br /> Street Number Direction <br /> de <br /> HOME or MAILING ADDRESS ( If Different from Site Address) 4130 Cover Street <br /> Street Number Street Name <br /> CITY <br /> STATE zip <br /> CA 90808 <br /> Long Beach <br /> PHONE #1 EXT. APN # LAND USE APPLICATION # <br /> ( 310 ) 323 - 3992 2012 1490611 <br /> PHONE #2 EXT. BOS DISTRICT LOCATION CODE <br /> ( 310) 930 - 5415 001 01 - STKN <br /> CONTRACTOR / SERVI TOR <br /> REQUESTOR L; 1ZJ ' 4 n': f BILLING ADDRESS <br /> Matt Thomas <br /> PHONE # ExT. <br /> BUSINESS NAME CGRS , Inc . I� � �• Y ' jO 627-8316 <br /> HOME or MAILING ADDRESSFAX # <br /> 5444 Dry Creek Road '� WIF? ( 916 ) 991 - 1177 <br /> CITY Sacramento QEp � (- IP 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 /> ' will be billed to me or m business as identified on this form . <br /> activity Y <br /> Y <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 /> APPLICANT ' S SIGNATURE : 7 2W&Mooa. DATE : 5 -6 - 19 <br /> PROPERTY I BUSINESS OWNER ❑ OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT IR Manager CG R S <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 information <br /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the Same time It iM t ai.or <br /> my representative . 1 <br /> TYPE OF SERVICE REQUESTED : adr <br /> COMMENTS: Scope of Work: 2019 <br /> • Saw cut 1 each 4 foot x 4 foot areas around direct bury spill buckets , demo , remove , pro JJ aipb(ceN 7 <br /> fill/ spill & vapor buckets with double wall OPW Edge buckets , testable 71SO - 41OCT OP#A1T4ARTTAt N <br /> valves <br /> MENr <br /> . Provide Spill bucket testing & OPI Inspections <br /> ACCEPTED BY : EMPLOYEE # : /4/J DATE:LS <br /> ASSIGNED TO : r L EMPLOYEE #: t;' DATE : <br /> Date Service Completed (if already completed ) : SERVICE CODE : 9 (J PIE : <br /> Fee Amount : �Gj CT Amount Pal L� OD Payment Date <br /> Payment Type Invoice # Check # 277rD Receiv d By : <br /> EHD 48-02-025 SR FORM (Golden Rod ) <br /> 07/17/08 <br />