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SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST <br /> -# <br /> silveria property _��LY� SQ <br /> OWNER OPERATOR BILLING PARTY❑ <br /> mrs ethel silveria <br /> FACILITY NAME <br /> SITEADORESS <br /> 1933 se ftN . el ee Hiawatha saeaH.m. avenue Try. sin., <br /> Mailing Address (If Different from Site Address) <br /> CITY STATE ca ZIP 95205 <br /> Stockton <br /> PHONE#1 APN# LAND USE APPLICATON# <br /> ( ) 209 467-8320 <br /> PHONE#2 Eka BOS DISTRICT - _ LOCATION.CODE <br /> 209 467-1006 AGE <br /> CONTRACTOR I SERVICE REQUESTOR <br /> REQUESTOR BILLING PARTY❑ <br /> advanced geo environmental <br /> PHONE# �• <br /> BUSINESS NAME same 09 467-1006 <br /> MAILING ADDRESS FAX# <br /> 837 shaw road ?09) 4674-118 <br /> CITY Y Stockton zip95215 <br /> BILLING ACKNOWLEDGEMENT: I,the undersgned property or business owner,operator or authorized agent of same, acknowledge that all site and/or project specific <br /> PusUt HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION hourly charges associated with Na project 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 wig be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes,Standards,STATE and <br /> FEDERAL laWS. <br /> APPLICANT SIGNATURE: l�/ ( ,Cy/�- C% ' —��y ""�' DATE: <br /> PROPERTY I BUSINESS OWNER ❑ OPERATOR/MANAGER ❑ OTHER AUnWRRED AGENT ❑ <br /> 11APXL Wis notthe B r�Pod ofWtlwrb2dw to signs rewind Title <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable,I,bre owner or operator of the property located at the above site address,hereby authorize the release of <br /> any and all results,geotechnical data and/or envimnmentallsde assessment infornetion to the SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DWION as soon <br /> as it is available and at the same time it is provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: C � <br /> COMMENTS: <br /> PAYMENT <br /> RECEIVED <br /> JUL 5 2001 <br /> PAN JOAQUIN GOUNTY <br /> UBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> INSPECTOR'S SIGNATURE: CONTRACrOR'S SIGNATURE: <br /> APPROVED BY: EMPLOYEEff: 09 <br /> 6 <br /> ( 1 DATE <br /> ASSIGNEDTO: EMPLOYEE#: ODD DATE <br /> Date Service Completed ('If al dy completed): SERVICECODE P I E: 0 <br /> Fee Amount Amount Paid Payment Date <br /> Payment Type Invoice#- Check# - Received By: <br />