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i <br /> t <br /> SAN JOAQUI . —OUNTY ENVIRONMENTAL HEALTH _—?ARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Lf 37c�S <br /> OWNER i OPERATOR <br /> CHECK If BILLING ADDRESS <br /> Mr. Dale Adema <br /> FACILITY NAME <br /> Wildwood Ranch <br /> SITE ADDRESS 15445 E Wildwood Road Stockton q�� �j- <br /> Street Number Direction Street Name Cit Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 2937 Veneman Ave (Suite C 275) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> Modesto <br /> PHONE#1 ExT APN# LAND USE APPLICATION# <br /> ( ) 203-140-01 PA-05-247 (MS) <br /> PHONE#2 Ext. BOS DISTRICT i LOCATIO ODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESSIA <br /> Nancy Rosijlek <br /> BUSINESS NAME PHONE# ExT. <br /> HOME or MAILING ADDRESS FAX# <br /> 902 Industrial W (209) -4228 <br /> CITY STATE CA ZIP 95240 <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, STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESSOWNER❑ 01kRATOR/NIANAG R 13 OTHER AUTHORIZED AGENT ED consultant <br /> /f APPL/CANT is not the BILLING PARTY,pr of 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 andEat tie same time it is <br /> provided to me or my representative. P,6ly <br /> TYPE OF SERVICE REQUESTED: I E\At R <br /> COMMENTS: /OIle <br /> J1/I ICj� 3a [>^MM 1�Yvly" SEP 13 <br /> I 1'FY�' <br /> /J j ,� SGOT70 SAN oP'QUW EN-Tp"- <br /> H�tTH DEPARTMENT <br /> APPROVED BY: EMPLOYEE#: ` DATE: .J <br /> ASSIGNED TO: EMPLOYEE#: _ 7 DATE: <br /> I Ili 7 <br /> Date Service Completed (if already completed): SERVICE CODE: _5- P 1 E:.—L <br /> Fee Amount: Amount Paid 0 kc, , VD Payment Date f`3 f <br /> Payment Type Invoice# Check# ! Received By: <br /> EHD 48-01-025 SERVICE REQUEST FORM <br /> REVISED 6-5-02 <br />