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SAN JOAQUIP' ':OUNTY ENVIRONMENTAL HEALTH ^EPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Verizon F"A000 1 846 hc�-" — -i' I/ <br /> OWNER l OPERATOR <br /> CHECK if BILLING ADDRESS <br /> E]Grltsko ❑ <br /> FACILITY NAME Verizon Lodi CA <br /> SITE ADDRESS 2500 West Turner Road Lodi 95242 <br /> Street Number Direction Street Name Cit Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#'I EXT. APN# LAND USE APPLICATION# <br /> (916) 205-9291 <br /> PHONE#2 EXT, BO$DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR I SERVICE REQUESTOR <br /> REQUESTOR <br /> Pamela E. Lawrence CHECK If BILLING ADDRESS El <br /> BUSINESS NAME PHONE# EXT. <br /> Sunw c st Engineering Constructors, Inc. (909)594-9890 <br /> HOME or MAILING ADDRESS 4780 Cheyenne Way FAX# <br /> (909) 594-6169 <br /> CITY Chino STATE CA ZIP 91710 <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: May 5, 2014 <br /> PROPERTY I BUSINESS OWNER❑ OPERATOR 1 MANAGER ❑ OTHER AUTHORIZED AGENT IR CEO - SunWest En ineerin <br /> IfAPPLICANT 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 environmental/site assessment information <br /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It i5 available and at the same time it IS provided to me or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: AIQF MF/yT <br /> COMMENTS: NO <br /> ACCEPTED BY: ty - )/� EMPLOYEE#: ] /'� DATE: /r1 <br /> ASSIGNED TO: � w, 1 EMPLOYEE#: 7 DATE: `f <br /> Date Service Completed (if already completed): SERVICE CODE: L jC/ PIE: Z 30 <br /> Fee Amount: -7) �S Amount Paid --Payment Date J <br /> Payment Type y Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM (Golden Rod) <br /> 07/17/08 <br />