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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # SERVICE REQUEST # <br /> RETAIL GAS STATION A 000 (py3 Sk <br /> � �R <br /> 2L� <br /> OWNER / OPERATOR <br /> APRO , LLC . CHECK If BILLING ADDRESS <br /> FACILITY NAME UNITED PACIFIC #5446 <br /> SITE ADDRESS 1403 COUNTRY CLUB BLVD , STOCKTON 95204 <br /> Street Number Direction Street Name City Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> SAME AS Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE #1 EXT. APN # LAND USE APPLICATION # <br /> ( 209 ) 943-2082 <br /> PHONE #2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> ROSS MCLAREN CHECK If BILLING ADDRESS El <br /> BUSINESS NAME PHONE # EXT. <br /> RM FUEL SYSTEMS 805 710-2006 <br /> HOME or MAILING ADDRESS FAX # <br /> 28030 VALCOUR DRIVE ( ) <br /> CITY CANYON COUNTRY STATE CA ZIP 91387 <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 /> 1 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 : /C&d� 7;1/ DATE : 05- 15-2021 <br /> PROPERTY / BUSINESS OWNER ❑ OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT ® CONTRACTOR <br /> If APPLICANT IS not the BILLING PARTY, /)roof Of authorization to Sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION : When applicable , 1 , 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 Is provided to me Or <br /> my representative . P <br /> TYPE OF SERVICE REQUESTED : DISPENSER REPLACEMENT <br /> COMMENTS: REMOVE EXISTING DISPENSERS AND INSTALL NEW GILBARCO ENCORE 700S DISPENSERS . Sq MAY O ?0 <br /> N <br /> JOA ?� <br /> NEq�TN �pgFNO uNT <br /> R T/19�N <br /> ACCEPTED BY: EMPLOYEE # : DATE : <br /> P7 <br /> Gil . WZ/ <br /> ASSIGNED TO : V of EMPLOYEE #: DATE : <br /> Date Service Completed ( if already completed ) : SERVICE CODE : I PIE : 2o44? <br /> Fee Amount: Lf r7co p <br /> Amount Pai , j) 2j Payment Date <br /> Payment Type ( Invoice # Check # 1 .2S 4EF,/c f� ReceiveLdlBy : <br /> EHD 48-02-025 SR FORM (Golden Rod) <br /> 07/17/08 <br />