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SERVICE REQUEST <br /> Type of Business or Property FACILITY ID IY SERVICE REQUEST , <br /> OWNER I OPERATOR �,,,� BILLING PARFf K <br /> MARK & PAULETTE RANUIO <br /> FACILrTY NAIAE "V mow. <br /> Or— <br /> SITE ADDRESS 8676 CANEPA ROAW�✓l��q� 999 <br /> stra.1 Rumbor Dlr&cllon SV-- N V Tr�� su�U <br /> Mailing Address (If Different from Site Addressl '=RM1-T C-AL..Tfq <br /> SAME AS ABOVE �L�V1Ci_S _ <br /> CITY STOCKTON STATE CA ZIP 95212 <br /> PHONE#1 Err• Apt;fl LAND USE APPLICAIIOq a <br /> (20� 522-0482 086-430-020 MS 94-51 <br /> PHONE#2 Ect. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQIIFSTOR BILLING PARTY❑ <br /> ZACHARY C. WONG <br /> BUSINESS NAME WONG ENGIN-EERS-, ..INC. _. -- .--.-,. PItnur b L'T. <br /> 476-0011 <br /> h`1AILINGADDRESS 4578 FEATHER RIVER DRIVE, SUITE A FAX# 476-0135 <br /> CITY STOCKTON STATE CA ZIP 95219 <br /> BILLING ACKN0WLEDGEh1Ef4T: I, the undersgned property or buslnesq gwner, operator or authortzed agent of same, acknowledge Thal all site and/or project speufie <br /> PUBLIC HEllTTI SERVICES ErrVIRONMENTAL HEALTH ONISIOtt hourly charges associated with this projW or activity will be billed to me or my business as Identified on tris toren. <br /> I also certity uTat I have prepared this application and that the work to be performed will be done irl accordance wdh all SAN JOAQUIN COUNTY Ordinance Codes. Standards,STATE and <br /> FEDERkI,laws. n. <br /> APPLICANT SIGNATURE: DATE: 10—fG-'-iQ <br /> (/ <br /> PROPERTY/BUSINESS OWNER ❑ OPERATOR/MANAGER ❑ OMER AtfmoerzED AGENT ❑— <br /> n APPucwr Is not Ina @iu+c PAg Pmol or audrorr:,don to stun it requbsd Title <br /> AUTHORIZATION TO RELEASE MFOR1,1ATION:Wherl applicable.I.the owner or operator of the property located al the above site address.hereby aulhonze the release of <br /> any and all results,geotechnical data and/or environmental/silo assessment into rnaton to the SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENWROMAENTAL HEALTH EWISION as soon <br /> as it Is available and al We same bine it is provided to me or my representatm. <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: t J <br /> SOIL SUITABILITY <br /> PAYMENT <br /> RECEIVED <br /> OCT 191999 <br /> SAN JOAQUIN COUNTY <br /> PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> INSPECTOR'S SIGNATURE: CONTRACTOR'S SIGNATURE: <br /> APPROVED BY: EMPLOYEE boo ( DATE: <br /> ASSIGNED 10: Vu L✓� EMPLOYEE r�: �) DATE: <br /> Date Service Completed (It air ady completed): }.' '� - v <br /> SERVICE CODE: ��0��— PIE: rte` <br /> Fee Amount: (7 Alnounl Paid Payment Date G � <br /> Payment Type Involce # Check r Receiyed By: <br />