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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />CHECK if BILLING ADDRESS <br />SERVICE REQUEST # <br />BUSINESS NAME <br />X00 �eA 201 co <br />OWNER/ OPERATOR <br />EXT. <br />El <br />Juan Ruiz <br />209 <br />CHECK If BILLING ADDRESS <br />FACILITY NAME Ruiz Property <br />FAX # <br />SITE ADDRESS 11671 <br />E. <br />Ada Ave. <br />( ) <br />Stockton <br />95215 <br />Street Number <br />Direction <br />Street Name <br />City <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />same <br />Street Number <br />Street Name <br />CITY <br />STATE ZIP <br />PHnNF #1 EXT. <br />APN # <br />LAND USE APPLICATION # <br />( 209) 923-0137 <br />103-270-08 <br />PHONE #2 EXT. <br />BOS DISTRICT Lj <br />LOCATION CODE <br />CONTRACTOR / SERVICE REOUESTOR <br />REQUESTOR <br />CHECK if BILLING ADDRESS <br />Abby Racco <br />BUSINESS NAME <br />PHONE # <br />EXT. <br />Live Oak GeoEnvironmental <br />209 <br />369-0375 <br />HOME or MAILING ADDRESS <br />FAX # <br />407 W. Oak St. <br />( ) <br />CITY Lodi <br />STATE CA <br />z'P 95240 <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, STATE and FEDERAL laws. <br />/' <br />APPLICANT'S SIGNATURE: &" (!—I DATE: q' 30 -7� 1 <br />PROPERTY / BUSINESS OWNER❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT L? G# 'VSV t% <br />