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SAN JOAQL._ —'OUNTY ENVIRONMENTAL HEALT►_ e,PARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> F—rT c,u)() ` Ll J C �5 <br /> OWNER/OPERATOR <br /> CHECK if BILLING ADDRESS <br /> Pacfic Gas &Electric <br /> FACILITY NAME pacific Gas &Electric, Stockton Service Center <br /> SITE ADDRESS West Lane95204 <br /> 4040 Stockton <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 /> ( ) 11-7 leo I <br /> PHONE#2 EXT. BOS DISTRICTLOCATION CODE <br /> ( ) 0C� � of <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR Kristin Reynolds CHECK if BILLING ADDRESS® <br /> BUSINESS NAMETAIT Environmental Services PHONE# EXT. <br /> 916 224-7280 <br /> HOME or MAILING ADDRESS FAX <br /> 11280 Trade Center Drive ( ) <br /> CITY Rancho Cordova STATE CA ZIP 95742 <br /> BILLING ACKNOWLEDGEMENT: 1, 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 /> 1 also certify that 1 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, S A and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> �I <br /> PROPERTY/BUSINESS OWNER[:] OPERATOR/NfANAGER ❑ OTHER AUTHORIZED AGENT LSI: Contractor <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to 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 JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and.at the same time it is <br /> provided to me or my representative. p <br /> TYPE OF SERVICE REQUESTED: La S T i\,e �CE/V T <br /> COMMENTS: -fut 14 <br /> 2017 <br /> tiy� N;; 04) <br /> ACCEPTED BY: mEMPLOYEE#: DATE: '7 1 l ) 7 <br /> ASSIGNED TO: Al", <br /> Pr ✓\ EMPLOYEE#: DATE: 7 - / V-1-7 <br /> Date Service Completed (if already completed): SERVICE CODE: f 9 PIE: �' <br /> Fee Amount: Lf CL Amount Paid c160,4 Payment Date 7 <br /> Payment Type / Invoice# Check# 5316-2— S-SS97 Rec ved By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />