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SERVICE REQUEST ) Revised 8/23/93 <br /> dFACILITY ID # _ RECORD ID # ]NVOICE # I <br /> 1 _ <br /> FACILITY NAME JON BRANDSTAD BILLING PARTY /' N <br /> SITE ADDRESS _ BAKER ROAD, EAST OF BEECHER MS-93-112 <br /> CITY STOCKTON CA ZIP e <br /> OWNER/OPERATOR JON BRANI)STAD 81LLiNG PARTY + j N <br /> DBA PHONE #1 t ) <br /> ADDRESS 4114 HUBR ARD AVE , PHONE #2 r y 931 - 4436 <br /> CITY STOCKTON STATE CA ZIP 9521 ' <br /> APN # Land Use Application # <br /> 089-170-49 `dS-93-112 Bos dist Location Code 1 <br /> CONTRACTOR and/or <br /> SERVICE REGUESTOR WONG ENGINEERS, INC , BILLING PARTY Y i N <br /> DBA PHONE #Y : y 476 - 0011 <br /> MAILING ADDRESS 4578 FEATHER RIVER DR. , SUITE A FAX # c ) 476-0135 <br /> CITY STOCKTON STATE CA ZIP 95219 <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned owner, operator or agent of same, acknowledge that all site and/or project specific <br /> PHS/EHD hourly charges associated with this facility or activity will be billed to the party ii"dentified•as the BILLING PARTY on <br /> Page i of this form. { U '7 ..'d <br /> SAN f <br /> I also certify that I have prepared this application and that the work to be performed wilt bkldone in accordance with all SAN <br /> JOAQUIN COUNTY Ordinance Codes and Standards State and Fpd aws. ENVIRON;r': <br /> APPLICANT'S SIGNATURE <br /> Title: PRES , Date: FEB. 4, 1994 <br /> AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, 1, the owner, operator or agent of same, of <br /> the property Located at the above site address hereby authorize the release of any and all results, geotechnical data and/or <br /> environmental/site assessment information to SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as <br /> it is available and at the same time it is provided to me or my representative. <br /> Nature of Service/ U(� /:Request: ,�/� SOIL SUITABILITY STUDY Service Code <br /> Assigned to 9'C¢Cc. Employee # 0 3�3 Date J / <br /> Date Service Completed _/ / Further Action Required: Y / N PROGRAM ELEMENT oZ� <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By <br /> RENS _/ / SUPV _j /_ ACCT —j V_ UNIT CLK _j /_ <br />