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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID # CHECK H BILLING ADDRESS SERVICE REQUEST # EMPLOYEE #: PHONE # Ext. `S tZOOI V�-7 q Single Family Residence 209 404-7700 HOME or MAILING ADDRESS OWNER I OPERATOR CHECK If BILLING ADDRESS E] Rodney D. Gaede and Linda D. Gaede 1502 Westbrook Court FACILITY NAME f209 1577-3553 SITE ADDRESS $476 CITY Modesto E. Kettleman Lane ZIP S Lodi 95240 street Number Direction Street Name City Zip Code ROME or MAILING ADDRESS (if Different from Site Address) Same as above Street Number Street Name CITY STATE ZIP PHONE #1 ENT. API # LAND USE APPLICATION ( 209► 639-7012 063-070-10 PHONE #2 EXT. ( 1 BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR Terry D. Harnillon EMPLOYEE M CHECK H BILLING ADDRESS BUSINESS NAME EMPLOYEE #: PHONE # Ext. SERVICE CODE: q P 1'E: �2 OL� r 209 404-7700 HOME or MAILING ADDRESS Payment Type FAX # Check # 1502 Westbrook Court f209 1577-3553 CITY Modesto STATE A ZIP S BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as identified on this form. 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 COUNTY Ordinance Codes, Standards, STATE and FEDERAL laws. APPLICANT'S SIGNATURE: DATE: PROPERTY I BUSINESS OWNER OPERATOR/ MANAGER 13 OTHER AUTHORIZED AGENT ® Contactor If APPLICANT is not the BILLING PARTY. proof of authorization to sign is required Title AUTHORIZATION TO RELEASE INFORMATION; When applicable, I, the owner or operator of the property located at the above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the s,time it is provided to me or my representative. TYPE OF SERVICE REQUESTED: Inspection and soil sampling for removal of 350 -gallon UST Alp,, _F4 COMMENTS: SAN JO 2 ZZ �� Hp�Mz� oLL� QA�AL ACCEPTED BY: &a i f Vi — i1, lJ t V ut (� n ] EMPLOYEE M DATE: {�-0 ASSIGNED TO: EMPLOYEE #: DATE: I ,i 2-Ltl Date Service Completed (if already completed): SERVICE CODE: q P 1'E: �2 OL� r Fee Amount: Amount P 4176b Payment Date ! Payment Type Invoice # Check # Recei d By: EHD 48-02-025 SR FORM (Golden Rod) REVISED 1111712003