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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Gas Station A Uco )Vo0 S R00 9 7 31 m <br /> OWNER/OPERATOR <br /> Flyers Energy, LLC CHECK If BILLINGADDRESSE] <br /> FACILITY NAME Flyers# 427 <br /> SITE ADDRESS 3300 <br /> Street Number Direction Waterloo qaoe Stoe4��,on <br /> HOME or MAILING ADDRESS (If Different from Site Address) 2360 Lindberg St <br /> Street Number Street Name <br /> CITY Auburn STATE CA ZIP 95602 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (530) 885-0401 x2104 <br /> PHONE#Z EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> Matt Thomas CHECK if BILLING ADDRESS <br /> BUSINESS NAME CGRS, Inc. PHONE# EXT. <br /> (916)991-1100 <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 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: DATE: 10-13-23 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT I� Compliacne Services Manager <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 IS provided to me or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: PAYMENT <br /> Perform SB989 Repairs per attached Scope of Work RECEIVED <br /> OCT 17 2023 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: \ i, <br /> . � EMPLOYEE#: DATE: IO 2- <br /> ASSIGNED TO: a 1 V ` EMPLOYEE#: DATE: I`; ( Z <br /> Date Service Completed (if already completed): SERVICE CODE: :2C1 P/E: , <br /> Fee Amount: r L ft, Amount Paid Payment Date L o <br /> Payment Type �1 Invoice# 5btr6k# I '4-0 Y57-1 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />