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02/22/2006 12:01 2094683433 EHD PAGE 02 <br /> SAN JOAQUBV COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type Of Business or Property �ACILITYY1110011 SERVICE REQUEST(i <br /> ,,krone Qb ..S o ) --/J /I., <br /> OWNER/OPERATOR CHECK R BILLING ADDRESS❑ <br /> nark rzarnur-) <br /> FAmay NAME <br /> (Yrilrlt . rVxrkotplttrr <br /> SrrEADDREss <br /> 1789 sae.eNunw. Mr�tlon Charter Jg N. Stockton 95 a06r 111 <br /> HOME or MALiNC ADDRESS (If DRferent from Sato Address) <br /> st.eat Numhar senor Name <br /> C,rry STATE ZIP <br /> PHONMII Er' APN9 LAND USE APPLICATION10 <br /> ( 209) 969-5200 <br /> PHONE 92 BOS DISTWGILOCATIONCODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> $slDe as above CHECK NBILLING ADDRESS <br /> BUSINESS NAME PHONE 8 <br /> HONE or MAILING ADDRESS FAxi1 <br /> ( I <br /> CITY STATE LP <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 <br /> or activity will be billed to me or my business as identified on this form. <br /> I also certify that I have prepared this applica'Ion and that the work to be performed will be done in accordance with all SAN JOAQUiN <br /> COUNTY Ordinance Codes,Standards,STATE.End F �7 ERAL laws. �.� p <br /> APPLICANT'S SIGNATURE: DATE: E—t <br /> PROPERTY/BUsixEss OwNERJax OPERATO IMANAGER 13OTHER ADTHORCLED ACE:VT 11JfAPPLICAi'VT is not the BILLING_P 77'.prwf of authorization t0 sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable,1,the owner or operator of the property located at the <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br /> information to the SAN JOAQLmv COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. <br /> TYPEOFSERVICE REQUESTED: UST Consultation <br /> COMMENTS: RECEIVED <br /> FEB 2 7 2000 <br /> SAN JOAOUIPi COUNTY <br /> ENVIRONMENTAL <br /> ACCEPTED BY: EMPLOYEE 0: 3 DAIE-EP <br /> ASSIGNED TO: EMPLOYEE#: 1 DATE: <br /> Date Service Completed (Ralready completed): SERWCE CODE: <br /> m <br /> Fee Amount: U' Amount Paid 3 U U Payment Date <br /> Payment Type ,/ Invoice 0 Chock 9 �- - Received By; i f� <br /> EHD 4802-025 SR FORM(Gulden Rad) <br /> REVISED 11117aOD3 <br />