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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY <br />ID # <br />SERVICE REQUEST # <br />Residential�0 <br />BUSINESS NAME <br />T&S West <br />0 P # <br />�E�9 <br />00 Z.L z <br />OWNER J OPERATOR <br />F� <br />Dennis Faist <br />HOME Or MAILING ADDRESS <br />CHECK If BILLING ADDRESS❑ <br />FACILITY NAME <br />8'41V')0 2021 <br />PO Box 1592 <br />SITE ADDRESS <br />(209)942-1368 <br />6631 S <br />Jack Tone Road <br />Stockton 95215 <br />Street Number Direction <br />Street Name <br />city Zin Code <br />HOME or MAILING ADDRESS (If Different from <br />Site Address) <br />6595 <br />S. Jack Tone Road <br />Date Service Completed (If already completed): <br />Street Number <br />Street Name <br />CITY Stockton <br />P J E: <br />STATE CA ZIP 95215 <br />PHONE #1 EXT, <br />APN # <br />LAND USE APPLICATION # <br />(209) 639-1581 <br />6b8I OZ) Payment Date �a <br />181-08-017 <br />Check # I �2 �3 rj <br />PHONE #2 EXT. <br />( ) <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR /SERVICE REQUESTOR <br />REQUESTOR <br />George Raley <br />CHECK If BILLING ADDRESS <br />BUSINESS NAME <br />T&S West <br />0 P # <br />�E�9 <br />NEW <br />EXT. <br />F� <br />652-7811 <br />HOME Or MAILING ADDRESS <br />FAX # <br />8'41V')0 2021 <br />PO Box 1592 <br />(209)942-1368 <br />CITY Linden <br />STATE CA <br />ZIP 95236 <br />BILLING ACKNOWLEDGEMENT: 1, 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, STATE and FEDERAL laws. <br />APPLICANT'S SIGNATURE: <br />PROPERTY /BUSINESS OWNER <br />IJAPPLICANT is not <br />DATE: l�Z?�ZDZI <br />OPERATOR /MANAGER ❑ OTHER AUTHORIZED AGENT <br />the BILLING PARTY. proof of authorization to sign is required VVV Title <br />AUTHORIZATION 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 all results, geotechnical data Al <br />environmental/site assessment <br />information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br />provided to me or my representative. <br />TYPE OF SERVICE REQUESTED: �rlaT E' t7r%c;h rte S cYJ <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />COMMENTS: kleceNee) I <br />r` �,c. PyY1Ul <br />`Cl/VJ'1t r <br />F� <br />��� 26 <br />8'41V')0 2021 <br />0NMFc0L/ <br />At <br />ACCEPTED BY: ==r/` 4 Z� <br />EMPLOYEE #: <br />DATE: <br />ASSIGNED TO: <br />EMPLOYEE #: <br />DATE: /5 <br />Date Service Completed (If already completed): <br />SERVICE CODE: <br />- <br />P J E: <br />Fee Amount: wAmount Paid:, <br />6b8I OZ) Payment Date �a <br />Payment Type Invoice # <br />Check # I �2 �3 rj <br />g Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />