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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# �U RVICE REQUEST# <br /> Cardlock 103998687 2 <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> ER Vine Stockton <br /> SITE ADDRESS 4733 s Hwy 99 Frontage Rd. Stockton 95215 <br /> Street Number Direction Street Name Cit Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 2825 Railroad Ave. <br /> Street Number Street Name <br /> CITY Ceres STATE CA ZIP 95307 <br /> ti <br /> PHONE#1 Exr. APN# LAND USE APPLICATION# <br /> (209 )537-0723 <br /> PHONE#2 ExT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR ? <br /> REQUESTOR CHECK if BILLING ADDRESSO <br /> BUSINESS NAME <br /> PHONE# EXT. <br /> Donlee Pump Company 209 537-9396 <br /> HOME or MAILING ADDRESS FAX# <br /> 2825 Railroad Ave. (209 )537-9398 <br /> CITY <br /> STATE Zip <br /> Ceres CA. 95307 <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 /> 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 I BUSINESS OWNER❑ OPERATOR/M AG R ❑ OTHER AUTHORIZED AGENT YkI <br /> If APPLICANT Is not the BILLING PARTY,proof of authorization to sign is required Titl e <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 as soon as It IS available and at the Same time it Is provided t0 me Or' <br /> my representative. AA <br /> TYPE OF SERVICE REQUESTED: PPA <br /> IVB` <br /> COMMENTS: oCiy <br /> y�4T�RON iN OO <br /> UN <br /> h�FpgRT Tq4 <br /> ACCEPTED BY: EMPLOYEE#: nn DATE: ,a ' <br /> � ow vv�+' lT <br /> ASSIGNED TO: EMPLOYEE#: V I DATE: ,�Q <br /> Date Service Completed (if already Completed): SERVICE CODE: 1 P i E• <br /> Fee Amount: Amount Pa' L1�,00 Payment Date <br /> Payment Type Invoice# Check# Recei ed By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />