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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR G <br /> Roman Strauther Pr CHECK If BILLING ADDRESSO <br /> FACILITY NAME Strauther Property, proposed mobile homes <br /> SITE ADDRESS 200 Best Rd. Stockton 95215 <br /> SVeet Number I DI:;ction Street Name city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) same <br /> Street Number Straw Name <br /> CITY STATE ZIP <br /> PHONE#1 ExT. APN# LAND USE APPLICATION# <br /> (209) 986-0561 103-220-21 <br /> PHONE#2 EXT. BOS DISTRICT ""ff LOCATION CODE <br /> t 1 U0y <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> Abby Racco CHECK if BILLING ADDRESS� <br /> BUSINESS NAME PHONE# Ex. <br /> Live Oak Geo Environmental 209 369-0375 <br /> HOME or MAILING ADDRESS FAx# <br /> 407 W. Oak St. ( ) <br /> CITY Lodi STATE CA ZIP95240 <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 /> I also certify that 1 have prepared this application and that the work to performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, ST d E <br /> APPLICANT'S SIGNATU DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT 11 <br /> /,fAPPLICANT is not the B/LLtNG 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 avail26le and at the same time it is <br /> provided to me or my representative. �•7q�1Y <br /> TYPE OF SERVICE REQUESTED: Review <br /> COMMENTS: <br /> V 3� (� ►-� 014 <br /> R �0�8 <br /> H 1O <br /> THD p'NFNT UN�Y <br /> 9RTNFNT <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: 0 EMPLOYEE#: DATE: <br /> Date Service Completed (if already Completed): SERVICE CODE: PIE: <br /> Fee Amount: Q Amount Paid 364-zoPayment Date l(br <br /> Payment Type L1 k Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />