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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> F <br /> I <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Residential - Pina Property Is-Poo16Ulq �V <br /> OWNER/OPERATOR <br /> Vanessa and Vigil Pina CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> Pina Property <br /> SITE ADDRESSTracy 95304 <br /> 11560 west Clover Road <br /> Street Number Direction Street Name Cit Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> SAME Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 ExT• APN# LAND USE APPLICATION# <br /> ( 209 ) 640-4909 212-260-220 Q� -'Ski) <br /> PHONE#2 ExT• BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR 4M III, <br /> REQUESTOR <br /> Brian Millman CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# ExT• <br /> Advanced GeoEnvironmental 209 467-1006 <br /> HOME or MAILING ADDRESS FAX# <br /> 837 Shaw Road ( ) <br /> CITY Stockton STATE CA ZIP 95215 <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 application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standar s, TATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNED OPERATOR/ NAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> If APPLICANT 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: a u <br /> COMMENTS: C I <br /> ve <br /> AUG p 1 201 <br /> � ORQUIN COlJ <br /> N&Ajy �rH NMEIVT N <br /> ACCEPTED BY: EMPLOYEE#: DATE: MEN <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P/E: 0 <br /> Fee Amount: Amount Pal Q� Payment Date S� <br /> Payment Type Invoice# Check# Z 1/ Rece ved by: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />