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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 <br /> OWNER/OPERATOR <br /> APRO, LLC. CHECK if BILLING ADDRESS O <br /> FACILITY NAME UNITED PACIFIC#5446 <br /> 95204 <br /> SITE ADDRESS 1403 COUNTRY CLUB BLVD. STOCKTON <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 MC AREN CHECK if BILLING ADDRESS 0 <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 /> 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: /CP441 N-- � DATE: 05-15-2021 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ® CONTRACTOR <br /> If APPLICANT is not the BILLING PARTY, Proof of authorization to sigh 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 /> t0 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. <br /> TYPE OF SERVICE REQUESTED: DISPENSER REPLACEMENT <br /> COMMENTS: REMOVE EXISTING DISPENSERS AND INSTALL NEW GILBARCO ENCORE 700S DISPENSERS. <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE M DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: <br /> Fee Amount: Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />