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SAN JOAQU.- COUNTY ENVIRONMENTAL HEALTh ,DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVI�E C�JE�� I <br /> OWNER/OPERATOR <br /> PG&E CHECK if BILLING ADDRESS E] <br /> FACILITY NAME PG&E <br /> SITE ADDRESS West Lane Stockton 95204 <br /> 4040 <br /> Street Number Direction Street Name City Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (916 ) 224-7280 taO u ` <br /> PHONE#2 EXT. 1 BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR Kristin Brown <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME Tait Environmental Services PHONE# EXT. <br /> 916 224-7280 <br /> HOME or MAILING ADDRESS 11280 Trade Center Drive FAX# <br /> CITY Rancho Cordova STATE CA ZIP 95742 <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 application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standar ,S TE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: 9/21/16 <br /> PROPERTY/BUSINESS OWNER 13 OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT Ij Contractor <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 <br /> above site address, hereby authorize the release of any and ail results, geotechnical data and/or environmental/site assessment <br /> —information to the SAN JOAQUIN COUNTY-ENVIRONMENTAL HEALTit-DEPARTMENT as soon-as itis available and at the same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: Replacement of Containment Boot On Was Drain U S-r `L <br /> COMMENTS: <br /> ACCEPTED BY: EMPLOYDATE: <br /> ASSIGNED TO: 1 EMPLOYEE#: DATE: 1 ply- I Its <br /> Z!ff±= IkL a4- �l D <br /> Date Service Completed (if already completed): SERVICE CODE: 131 E: A <br /> Fee Amount: l O Amount Paid I OD Payment Date ct ZO `(p <br /> Payment Type Invoice# Check# 05 CIGI 3 Received B . <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />