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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # c SERVICE REQUEST # <br /> Tractor Services - �7 iZ (�0MOSO <br /> OWNER OPERATOR <br /> Margo Bentzdvers , Trustee )"'A �-A 10W �' l tc507� CHECK If BILLING ADDRESS ❑ <br /> FACILITY NAME <br /> Associated Tractor Service , Inc . <br /> SITE ADDRESS W Charter Way Stockton 95206 <br /> 1323 Street Number Direction Street Name City T Zip Code <br /> HOME or MAILING ADDRESS ( If Different from Site Address ) Lagorio Road <br /> 4750 Street Number Street Name <br /> CITY STATE CA ZIP <br /> Stockton 852151811 <br /> PHONE #1 EXT. APN # LAND USE APPLICATION # <br /> (209 ) 483 -7285 163 -230 - 050 <br /> PHONE #2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> Gregory Stahl , Vice President CHECK If BILLING ADDRESSED <br /> BUSINESS NAME PHONE # EXT. <br /> Ground Zero Analysis , Inc. (209 ) 5224119 <br /> HOME or MAILING ADDRESS FAX # <br /> 1172 Kansas Avenue ( 209 ) 522 -4227 <br /> CITY Modesto STATE CA ZIP 95351 <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 work to be performiqdpill be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Stai , :lards, STATE and FEDERAL laws ; f f' <br /> APPLICANT ' S SIGNATURE : J `tr.1 DATE : <br /> PROPERTY / BUSINESS OWNER ® OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT ❑ r _ <br /> If APPLICANT is not the BILLING PARTY, proof of authorizaticin to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION : When applicable , I , th .n owner or operator of t property located at the abcve <br /> site address , hereby authorize the release of any and all results , geotech tical data and/or environ a tat/site assessment informat on <br /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon C s it is available and at th same time it is nrovided to ME or <br /> my representative . <br /> TYPE OF SERVICE REQUESTED : SOIIrings <br /> COMMENTS : <br /> SgNaO'�QU/ 6 049 <br /> yF�G EpgRiTA/yr1io <br /> ACCEPTED BY : 4 g T EMPLOYEE # : DATE : <br /> ASSIGNED TO : ,. l• `�/ EMPLOYEE # : DATE: <br /> Date Service Completed ( if already completed ) : SERVICE CODE : ( PIE : ✓ 1 <br /> Fee Amount : — Amount Paid Z Stogy �� Payment Date <br /> G <br /> Payment Type Invoice # Check # 7s�3s� 5 Received By : <br /> EHD 48- 02-025 SR FORM (Golden Rod ) <br /> 07/17/08 <br />