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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # ( SERVICE REQUEST # <br /> Communications Generator USTd �O � " ' <br /> OWNER / OPERATOR EX <br /> CHECK If BILLING ADDRESS <br /> Sprint United Management Co . <br /> FACILITY NAME <br /> Sprint United Management Co . <br /> SITE ADDRESS 3807 CORONADO ST. STOCKTON55204 <br /> Street Number Direction Street Name Cit Zi Code <br /> HOME or MAILING ADDRESS ( If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE #1 EXT. APN # LAND USE APPLICATION # <br /> ( ) <br /> PHONE #2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR PETER JAUREGUI CHECK If BILLING ADDRESS <br /> BUSINESS NAME JAUREGUI & CULVER , INC . PHONE # E"T• <br /> ( 760-) 7410518 <br /> HOME or MAILING ADDRESS FAX # <br /> 959 W. MISSION AVE ( 760 ) 743-0621 <br /> CITY ESCONDIDO STATE CA . ZIP 92025 <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 performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards , STATE and FEDERAL laws . <br /> APPLICANT 'S SIGNATURE : DATE : `�/ISIS-2d2� <br /> PROPERTY / BUSINESS OWNER ❑ OPERATOR / ANAGER OTHER AUTHORIZED AGENT ®PRESIDENT <br /> If APPLICANT is not the BILLING PARTY, proof 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 as soon as It IS available and at the same time 0 rovlded to me or <br /> my representative . 1'M <br /> TYPE OF SERVICE REQUESTED : PERMIT FOR TANK RETROFIT REPAIR <br /> COMMENTS : T <br /> s ) � ' 9 ?0?0 <br /> ogQ <br /> HEA TN OF ARTA 1NTY <br /> MENT <br /> ACCEPTED BY : RI V�—G� EMPLOYEE # : DATE : <br /> ASSIGNED TO : G � p 0 EMPLOYEE # : DATE : 1011g712-0 <br /> Date Service Completed ( if al ready confp eted ) : SERVICE CODE : IqS PIE : 24309 <br /> Fee Amount : 4t3� ev Amount Pai L OCJ Payment Date f d <br /> Payment Type t/7 4o) Invoice # Check # S� 9Z Receive By : <br /> EHD 48-02-025 SR FORM (Golden Rod) <br /> 07/17/08 <br />