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r SAN JOAQUE—COUNTY ENVIRONMEN.N-�HEALTA APARTMENT <br /> I SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> CHECK if BILLING ADDRESS <br /> I )AGILITY NAME <br /> Podesta Pra ert <br /> SITE ADDRESS 6655 N Beecher Road Stockton 95212 <br /> I Street Number Directlo Street N me Ci Zl Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> P.O. Box 170 <br /> Street Number Street Name <br /> CITY Linden STATE ZIP 95236 <br /> CA <br /> PHONE#t Err. APN# LAND USE APPLICATION# <br /> } <br /> I ()-- 0-057 PA-04-760 <br /> PHONE#2 Exr. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESSO <br /> BUSINESS NAME PHONE# EXT. <br /> -- Non] 0- Anderson and Assonmates- Inr- (209)367-3701 <br /> HOME or MAILING ADDRESS FAX# <br /> 209 369-4228 t Orl, 1 <br /> CITY STATE ZIP 240 <br /> i. 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,Standards,ST EDERAL la <br /> APPLICANT'S SIGNATURE: DATE: fo S <br /> PROPERTY/BUSINESS OWNER O TOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> IfAPPLICRNT is not the BILLING PARTY.Proof of authorization to Sign is required Title <br /> A THORIZATION 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 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. i <br /> TYPE OF SERVICE REQUESTED: SOII Suitability Study eVieW PAY Mt-- � <br /> COMMENTS: 3 <br /> JU14 6'2005 <br /> SAN JOAQUIN COUNTY <br /> y, ENVIRONMENTAL <br /> /rte <br /> HEALTH DEPARTWIT'T <br /> ApIPRpVED 13Y: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: ' <br /> Dante ServlCe C pleted (If already completed): SERVICE CODE: P/E: <br /> Fee Amount: ., Amount Paid - Z v <br /> Payment Date I <br /> Payment Type I Invoice# Check# ecei ed By <br /> EHD 48-01-025 <br /> REVISED 6-5-02 SERVICE REQUEST FORM <br />