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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # AERVICE REQUEST # <br /> Gas Retail A000ob '45 Ixt) Uq3 0 <br /> OWNERL �/ OPERATOR <br /> Sam 1 Iirsch CHECK If BILLINGADDRES5 <br /> ort LITY ME <br /> top <br /> SITE ADDRESS 20 W Turner Road Lodi 95240 <br /> Street Number Direction Street Name city ZI Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Same as above Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE #1 ExT• APN # LAND USE APPLICATION # <br /> ( 209 ) 369-3697 <br /> PHONE #2 ExT. BOS DISTRICT LOCATION CODE <br /> ( 209 ) 327-6171 <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR CHECK If BILLING ADDRESS ® <br /> Deborah Jones <br /> 10PHONE # Exr. <br /> �Yi�el� Contractors 209 461 -6337 <br /> HOME or MAILING ADDRESS FAX # <br /> 2535 Wigwam Drive ( 209 ) 461 -6342 <br /> CITY Stockton 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 <br /> or 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, �S/T,A�TE� and <br /> FEDERAL laws . <br /> APPLICANT'S SIGNATURE *, 4.4 J fO tk ►'L DATtEy� :tt 10/ 12/2021 <br /> PROPERTY / BusINESSOwNER ❑ OPERATOR IGI . ANAGER ❑ OTHERALITHORIZEDAGENT101 Administrative Assistant <br /> If APPLICANT is not the BILLLVC PARTY, proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION : When applicable, 1 , the owner or operator of the property located at the <br /> above site address , hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at th�same time it is <br /> provided to me or my representative . L Q <br /> TYPE OF SERVICE REQUESTED : i f S Trwc& <br /> COMMENTS: OCT <br /> SqN <br /> JOA 3 ?021 <br /> HEATH pg4FNO LN7 <br /> RTMEN <br /> ACCEPTED BY: +`'G C ' EMPLOYEE #: DATE: / U / <br /> ASSIGNED TO : J ' _ EMPLOYEE #: DATE : <br /> Date Service Complet d ( if air ady completed) : SERVICE CODE: P 1 E.2 � <br /> Fee Amount: ltc.d Ow Amount Paidb� Payment Date �0 <br /> Payment Type Invoice # Check # Received By : <br /> EHD 48-02-025 13 Z 737 SR FORM (Golden Rod) <br /> REVISED 11 /17/2003 <br />