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SAN JOAQUbrISOUNTY ENVIRONMENTAL HEALTH`ePOPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> Mr- Rochard Green <br /> FACILITY NAME <br /> Green Property <br /> SITE ADDRESS 39324 E Lone Tree Road Oakdale 95361 <br /> �' �� Street Number I Dirt St,.et Nae DAY My Cotle <br /> HOME or MAILING ADDRESS (If Different from Site Atltlress) <br /> 3 /GU Street Number Street Name <br /> CITY //atdtlllL T TE <br /> PHONE#1 Exr. APN# LAND Lite APPLICATION III <br /> 12091 3qg- D1/0/ 1 229-140-11 C—PA-04-693 <br /> PHONE#2 Exr' BOS DISTRICT LOCATION CODE <br /> I 1 <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK if BILLING ADDRESS <br /> Dave Wplrh <br /> BUSINESS NAME PHONE It En' <br /> HOME Or MAILING ADDRESS FAx# <br /> 902 Industrial Way I l 369-4228 <br /> CITY LodSTATE 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 /> also certify that 1 have prepared this a 'cation ano that th rk to b fo ed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Stand, ,S TPt and DERA a S. <br /> APPLICANT'S SIGNATURE DATE:DATE: <br /> PROPERTY/BUSINESS OWNER LID OPERATOR/MANAGER If OTHER AUTHORtzEDAGENT O <br /> If APPLICANT 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 t0 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 /> TYPEOF SERVICE REQUESTED: .Soli Suitability .Study Review <br /> COMMENTS: <br /> -Ap� /�'p '- 7 RECEIVED <br /> � br <br /> ,rcw ll,�vrvW APS 2 5 2005 <br /> ® B/W JOAQUIN COU <br /> APPROVED Eli. EMPLOYEE#: ApPA /5 s <br /> ASSIGNED I EMPLOYEE#: DATE: <br /> Date Service o pleted (if already complet d): SE ICE CODE: _ P/E: � <br /> Fee Amount: 7Amount Paid - - r Payment Date <br /> Payment Type ✓ Invoice# Check# r C�._ Received By: , <br /> EHD 48-01-025 SERVICE REQUEST FORM <br /> REVISED 6-5-02 <br />