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UHl\ U VHS V ll\ \.V U1\1 1 l:Ll�\11�V:V RL'1\1 HL 11liHL 1 ll LLl Hl\11\1L`1\1 <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> CHECK if BILLING ADDRESS <br /> FACILITY NAME <br /> Mariposa Road Prol2erty <br /> SITE ADDRESS 8868 & 8998 E Mariposa Road Stockton 95215 <br /> Street Number treat city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) P.O. BOX 30602 <br /> Street Number St.t Name <br /> CITY STATE ZIP <br /> Stockton CA 95215 <br /> PHONE 91 EXT. APN# LAND USE APPLICATION# <br /> I ) 181-090-11 & 181-090-02 PA-04-347 <br /> PHONE#2 EXT. SOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS El <br /> BUSINESS NAME PHONE# ExT. <br /> HOME Or MAILING ADDRESS FAX III <br /> 2 Industrial W ( )369-4228 <br /> CITY Lodi <br /> STATE CA ZIP 95240 <br /> 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 a lication and that the work to be performed will be done in accordance with all SAN JOAQUM <br /> COUNTY Ordinance Codes,Stan STT ,a EDERAL laws. <br /> APPLICANT'S SIGNATUR DATE: <br /> PROPERTY/BUSINESSOWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT® Consultant <br /> I.fAPPLICANT is not the BILLING PARTY proof of authorization to.sign is required Title <br /> AUTHORIZATION 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. <br /> TYPE OF SERVICE REQUESTED: SOII Suitability Study/Nitrate Loading Study Review <br /> COMMENTS: � t OS /QQ/l1f ✓1 f^'�'HL� 9V f2" f11 <br /> �10&' "4 <br /> . .s' <br /> a 4w,# rou?'� <br /> apo P 5 couNN <br /> APPROVED BY: I EMPLOYEE M [ N NVI N <br /> ASSIGNED TO: -'EMPLOYEE#: 6 D <br /> Date Service 6ompleted (if already completed): SERVICE CODE: S� P I E: 2 <br /> Fee Amount: I Amount Paid ?1171 ':�KQ Payment DatePaymentType Invoice# Check# Received By: <br /> EHD 48-01-025 SERVICE REQUEST FORM <br /> REVISED 6-5-02 <br />