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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />BUSINESS NAME <br />SERVICE REQUEST # <br />GA5 s �, , a,.. <br />I oexvl� O <br />HOME or MAILING ADDRESS <br />sRj(jay 152 <br />OWNER I OPERATOR <br />( ) <br />CHECK if SICCING ADDRESS <br />United Pacific <br />1 Amount Paid <br />FAcILnYNAME United Pacific 76 Facility #5447 <br />Payment Type Invoice # <br />SITE ADDRESS 1469 East <br />Hammer Lanep <br />CECtOn <br />Street Number Direction <br />Street Name <br />.StC(J ty <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />4130 <br />Cover Street <br />Street Number <br />Street Name <br />cirY Long Beach <br />STATE CA 90808 <br />PHONE91 ExT. <br />APN # <br />LAND USE APPLICATION # <br />(310)323-3992 2012 <br />PHONE#2 E T. <br />BOS DISTRICT <br />11 <br />LOCATION CODE <br />1 <br />( 310) 930-5415 <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />Matt Thomas CHECK If BILLING ADDRESS <br />BUSINESS NAME <br />PHONE# EXT' <br />CGRS, Inc. <br />f 6261 627-8316 <br />HOME or MAILING ADDRESS <br />FAX# <br />5444 Dry Creek Road <br />( ) <br />CITY Sacramento STATE CA ZIP 9583 <br />BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br />acknowledge that all site andlor project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated With this project or <br />activity vrill be billets 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 W)I be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, STATE and FEDERAL laws. <br />APPLICANT'S SIGNATURE: DATE: <br />PROPERTY I BUSINESS OWNER OPERATORIMANAGER © OTHER AUTHOR1ZEDAGENT q Manager CGRS <br />If APPLICANT Is not the BILLING PARTY, proof of authorization t0 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 environmentallsite 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. <br />TYPE OF SERVICE REQUESTED: � � / P <br />COMMENTS: <br />ACCEPTED BY: lZI'vL-o'— � <br />EMPLOYEE #: <br />DATE: <br />ASSIGNED TO:sh01e*A <br />EMPLOYEE P <br />DATE: <br />Date Service Completed (if already completed): <br />SERVICE CODE: f , Z P 11; 2-1-30e7 <br />Fee Amount: 0 / ,G2 , o -O <br />1 Amount Paid <br />Payment Date <br />Payment Type Invoice # <br />Check # Received By: <br />EHD 48.02-D25 SR FORM (Golden Rod) <br />07117108 <br />