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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # SERVICEREQUEST # <br /> Gas Station (�C� U � nS� OJ (Q� <br /> OWNER / OPERATOR <br /> Kash Ban CHECK if BILLING ADDRESSO <br /> FACILITY NAME <br /> Save on Fuel <br /> SITE ADDRESS 420 W Yosemite Manteca 95337 <br /> Street Number Direction Street Name Cit Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE Zip <br /> PHONE #1 EXT. APN # LAND USE APPLICATION # <br /> ( 209) 707-3385 ;ZI A 3 f?W <br /> PHONE #Z EXT• BOS DISTRICT LOCATION CODE <br /> ( 510 ) 393=6916 11 005 <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> Matt Thomas CHECK if BILLING ADDRESSX <br /> BUSINESS NAME PHONE # EXT. <br /> CGRS , Inc . 916 ) 991A100 <br /> HOME Or MAILING ADDRESS FAX # <br /> 5444 Dry Creek Road ( ) <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 : DATE : 6/9/2021 <br /> PROPERTY / BUSINESS OWNER ❑ OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT © Manager - CGRS , Inc . <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 . <br /> TYPE OF SERVICE REQUESTED : <br /> COMMENTS : <br /> UST Repair permit inspections <br /> ACCEPTED BY: Sfax C ��/ti �t _ EMPLOYEE # : DATE: <br /> ASSIGNED TO : �� o EMPLOYEE # : DATE: C�11 <br /> Date Service Completed (if already completed) : - SERVICE CODE: / e7g 2. �� P 1 E : 2 ,oe <br /> cej Amount Pa c D � Payment Date 10 <br /> Fee Amount: )4141 /k <br /> Payment Type ` Invoice # Check # 1'Z Zy'7Received By: <br /> EHD 4&02-025 2/ Z 273 Z� SR FORM (Golden Rod ) <br /> REVISED 11 /17/2003 � Z ip� 3342L7 <br /> �z � `1ZF3Sb <br />