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f <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID 0 SERVICE REQUEST# <br /> Residential �� I� - � . <br /> OWNER/OPERATOR <br /> Paul Schuler CHECKHBiLLIN6Aoortess <br /> FAcanY NAPE Schuler Residence <br /> Sn ADoRm Stoneridge rd Tracy, CA 95304 <br /> 3960 sbvot Number Di - Z12 c <br /> HOPE or MAKmG ADDRESS (If Different from Site Addraas) Stoneridge rd <br /> 3956 s r <br /> CITY Tracy STATE CA . Zip 95304 <br /> PHONE 01 EXT. [WN-! LAND USE APPLtcAnoN# <br /> ( 520)631-5720 d 3 1 <br /> PHONE 82 Eirr. BOS DISTRICT LOCATION CODE <br /> ( ) S rc <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR Paul Schuler CHECK if BiLuao ADDREJ3 <br /> BUNNIS3 NAMEN/A PHONE# <br /> HOME or mAiuNG ADDRESS 3956 Stoneridge rd Fat# <br /> c,TY Tracy STATE CA zp 95304 <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 bave prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, and DRAlas. <br /> APPLCANT'S SIGNATURM w <br /> DATE: 4(0/ <br /> PROPKRTY/Busm&u OWNERCW �D Zd <br /> OPERATOR/MANAGER ❑ OTHYR AUTHORIZED AcE.vr❑ <br /> If APPLICANT is not the BILLING proof of authorization to sign is required Title <br /> AUTHORI.ATION 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 a.11 results, geotechnical data and/or environmentaUsite assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same timc it is <br /> provided to me or my representative. <br /> TYPE OFSERm REQUESTED:Check install of water filtration system, 1. <br /> Colmms: �e./i4y iL c,f ,I4trwfi-" %,Ysferh Dc,;s;C-e <_mc:l t. sy51(MS C"Ic e" t IP S;I, cS r-1.)�J �F V'f 1v C(. J5 friCL1}IJi1 fjr WIDbi'e NoPub. D <br /> MAR 26 20 <br /> 22 <br /> S,4 N j04 QUIN <br /> HEL'RONMENTU 11' <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: j viel,1 ce EMPLOYEE#: DATE: j/L 6/7 o <br /> I <br /> Date Service Completed ('ti already completed): SERVICE CODE: JG, PIE: I <br /> Fee Amount: �5 Amount Paiwf ,� Payment Date , <br /> Payment Type S� Invoice# Check# 1b70s 3s Reclived By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />