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SAN JOAQU'OUNTY ENVIRONMENTAL HEALTH mWARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> SP-Cc (+ -2- -71s <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> Mr. Ron Dahnke <br /> FACILITY NAME <br /> Proposed Jiffv Lube Parcel <br /> SITE ADDRESS 25560 N Highway 99 Acampo 95220 <br /> Street Number Direction Street Name City Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 25533 North Highway 99 W. Frontage Rd <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> Acarnpo CA 95220 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (209)336 2213 005-141-35 RX-@4-427 M- G5 y <br /> PHONE#2 Ext. BOS DISTRICI LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> Nancy ERQsulek <br /> BUSINESS NAME PHONE# EXT. <br /> HOME Or MAILING ADDRESS FAX# <br /> 902 Industrial Way (209)369-4228 <br /> CITY Lodi <br /> STATE ZIP <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 /> 1 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,Standar ,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE' - DATE: 14 <br /> PROPERTY/BUSINESS OWN'rb OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> IfAPPL/CANT is not the BILLING PARTY,proof of authorization to sign is required Tele <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:SOII SuitabilityStudy Review �'AYiVl V L-L- <br /> 11 <br /> COMMENTS: <br /> 7� V 105 <br /> SAN JOAQUIN COUNT`( <br /> c <br /> ENVIRONMENTAL <br /> 7�/�f� 30 HEALTH DEPAR EN <br /> DATE:# <br /> MPLOYEE : <br /> APPROVED BY: Et l�� <br /> ASSIGNED TO:. ` EMPLOYEE#: 2 DATE: i1�2r J <br /> Date Service Completed (if already completed): SERVICE CODE: <br /> Fee Amount: C Amount Paid ,�� PaymentDate <br /> Payment Type hnvoice# Check# Rec iveclBy:�I, 1 <br /> 1 <br /> EHD 48-01-025 SERVICE REQUEST FORM <br /> REVISED 6-5-02 <br />