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Jan=27-04 04:51P P -02 <br /> SAN JOAQUI COUNTYF,NVIRONMENTALHEALTHllEPAT TMFNT <br /> SERVICE REQUEST <br /> Type of Business Or Property FACILRY ID# SERVICE REQUEST If <br /> Agriculture - Stables 5� 1 -�lb 76 <br /> OWNER/OPERATOR <br /> George Sperry CHECK II BILLING ADDRESS❑ <br /> FACILITY NAME <br /> S err Ranch Stables .- <br /> SITE ADDRESS 1957 McAllen Road Stockton " 95212 <br /> Street Number 07rcctlon Sir."N-Ift cft Zia Cgdg <br /> HOME or MAILING ADDRESS (If Different from She Address) <br /> �— Street Number _ilrset Name <br /> CITY STATE X ZIP X <br /> A <br /> PWME#I Exr. APN# LANDU9EAPPLIOATIONe <br /> p <br /> ( 209) 931-1115 092-140-01 1 il,,li- U3 ' 3L/ 6 <br /> PHDME#2 EaT BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUEsTOR <br /> Scott D. Rishwain CNECK NBRLniG AO11E9 <br /> BUSINESS NAME PHONE# Ex" <br /> X, March Lane 70, LLC 209 47_3_-2800 <br /> x Home Or MAILING ADDRESS FAy# <br /> 2800 W. March Lane, Suite 220 (209 ) 473-2885_ <br /> X CITY Stockton STATE CA 7JP 95219 <br /> BILLING ACKNOXVLF,DGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project Specific ENVIRONMENTAL IIEALTI I DEPARTMENT hourly charges associated with this project or <br /> activity will be billed to one or my business as identified on this form. <br /> I also certify that i have prcparcd this applicati nd that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,.Standards,S FT/FRAf.laws. <br /> X <br /> XAPPLICANT'S SIGNATURE: ryI DATE: 1/28/04 �— <br /> PROPERTY/BUSINESS OWNER❑ PKRATOR/MANAGER lJ QnIERAUTHORIZEDAGENT WY Applicant/Buyer <br /> tfAPPt rCANT is not the RA,t fNC PARTY,proof of authorization to sign is required Arta <br /> AUT11OR1LATION IQ ULEASE 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 cnviTonmenial/site assessment <br /> information to the SAN JOAOUtN COUNTY RNVIRONMFNTAI.HFALTIi DEPARTMENT as soon as it is available and at thme time it i <br /> �as <br /> provided to me or my representative. PA`/MEiS <br /> TYPE OF SERVICE REQUESTED: S I / S✓t ! R�t� �+ _ �, R <br /> _COMMENTS: nit <br /> Z-5; Yt�t <br /> AL <br /> l llo' HFALTH DE AROM NT <br /> ACCEPTED BY: 4 - EMPLOYEE#: 1 DATE: �` O <br /> ASsIGNEDTO: / - EMPLOYEE#: / DAZE: <br /> Date Service Completed (if*k"d✓y cvompleted): SERVICE CODE: <br /> Foe Amount: Amount Paid Wv P--a_y_ment Data <br /> Payment Typo invoicu# Check# Received By: :',.f_ <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/172003 - <br />