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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # SERVICE REQUEST # <br /> F c� 0 , DO <br /> OWNER / OPERATOR Steve Kludt CHECK if BILLING ADDRESS ❑ <br /> FACILITY NAME Kludt Trucking <br /> SITEADDRESS 1126 1 E Pine St Lodi 95241 <br /> Street Number Direction Street Name City Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Strout Name <br /> CITY STATE ZIP <br /> PHONE #1 ExT. APN # LAND USE APPLICATION # <br /> ( 209 ) 466-8969 0 010 V 2 <br /> PHONE #2 ExT• SOS DISTRICT00 / LOCATIOQDE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR Megan Mitchell CHECK If BILLING ADDRESS ® <br /> BUSINESS NAME PHONE # Ems' <br /> Elite IV Contractors 209 461 -6337 <br /> HOME or MAILING ADDRESS 2535 Wigwam Dr FAX # <br /> ( 209 ) 461 -6342 <br /> CITY Stockton <br /> STATE Ca ZIP 95205 <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 or <br /> activity will be billed to me or my business as identified on this form . <br /> also certify that I have prepared this application and that the ork to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards, STATE and FEDERAL la <br /> APPLICANT'S SIGNATURE : A DATE : 6/25/2020 <br /> PROPERTY / BUSINESS OWNER ❑ 4eiLLINGPART <br /> P TOR / MANA OTHER AUTHORIZED AGENT © office Assistant <br /> If APPLICANT IS not Y, pro 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 above <br /> site address , hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information <br /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT a5 soon as it IS available and at the same time It iS provided to me or <br /> my representative. P <br /> TYPE OF SERVICE REQUESTED : i C T <br /> COMMENTS: IZLJ <br /> SAN J UL 02 2020 <br /> HEOA <br /> gITHD pMFNTq� Ty <br /> ARTMEN <br /> ACCEPTED BY: C t / EMPLOYEE #: DATE: ice! <br /> ASSIGNED TO : S C Q EMPLOYEE #: DATE: 1 <br /> Date Service Completed (if already completed) : SERVICE CODE: PIE: <br /> Fee Amount: i1 � � OC Amount Pai 60 DD Payment Date `J <br /> Payment Type TS��� ( (J Invoice # Check # / O �) g ) .FE Received By: <br /> EHD 48-02-025 SR FORM (Golden Rod) <br /> 07/17/08 <br />