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SAN.JOAQUIN COUNTY ENVIRONMENTAL HEALTH biPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br />�. OWN E R I O P ERATOR <br /> John Tronkle G CHECK if BILLING ADDRESS <br /> 1 FACILITY NAME <br /> SITE ADDRESS S .-os-er•RRoadd Tracy 95304 <br /> 65treat Number Direction Streef'Name i i ode <br /> HOME or MAILING ADDRESS (if Different from Site Address) S. Koster Road <br /> 24551 Street Number .Street Name <br /> CITY ,j ' ` � ;II': ::.v�sF' >rr,� eMw..^..... ..ansa. ._':.r^'. .r7TATE 1- ZIP <br /> Tr ' California <br /> PHONE#1 EXT. APN# LAND USE.t4P ILP CATION# <br /> (559)897-5876 255-310-20 'PA 07-303 �'� ��` <br /> PHONE#2 Err. BOS DISTR1ej_.-- LOCATION CODE <br /> 209-835-2838 S 171 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR Nancy Rasulek <br /> CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE# Exr. <br /> Npil 0- Andpirson and Associates, Inc. (209)367-3701 <br /> HOME or MAILING ADDRESS FAX# <br /> 902 Industrial Way (209) 9-422 <br /> CITY Lod STATE CA ZIP 25240 <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 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,S TE and FEDERAL laws. <br /> APPLICANT'S SIGNATU I DATE: 9-10 0 "_Q <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/rll A AGER OTHER AL3THORIZED AGENT D <br /> IfAPPLICANT is not the BILLING 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 available and at the Same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: M C7YLr -� Gp �r i�C� �' 0-0(-.c-S—e c%,-t--S' !G.-t <br /> dq <br /> COMMENTS: RECEIVED <br /> 7 , 16 c �nc�� OCT a 0 2007 <br /> 5A r- IVI ONiMENTAL <br /> APPROVED BY: C>� I L)eC,&A EMPLOYEE#: C)2­2 JDATEt IEA�YgO VAA VL <br /> 69 U <br /> ASSIGNED TO: -T-AS c EMPt OYEE#; T U LCC- DATE: (p f E/0 7 <br /> Date Service Completed (If already completed): SERVICE CODE: � P I E: Z,(aV-2-- <br /> Fee <br /> Fee Amount:- '� c U• C'V Amount Paid A90 , 6 0 Payment Date 1 C- {010 <br /> Payment Type t/ Invoice-# Check# 1 2 2_2 Received By: N (�S <br /> y <br /> EHD 48-01-025 SERVICE REQUEST FORM <br /> REVISED 6-5-02 <br /> i <br />