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SAN JOAQT*OUNTY ENVIRONMENTAL HEALTINEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Utility Provider 2 v� <br /> OWNER/OPERATOR CHECK If BILLING ADDRESS❑ <br /> Pacific Gas and Electric Company <br /> FACILITY NAME pacific Gas and Electric Company <br /> SITE ADDRESS 4040 West West Lane Stockton 95204 <br /> Street Number I Direction I Stmet Name city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Sarre aS OWner Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (209 ) 942-1728 117-020-01 <br /> PHONE#2 En. BOS DISTRICTLOCATION CODE <br /> I ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR Jason Musial CHECK If BILLING ADDRESS <br /> PHONE# E[r' <br /> BUSINESS NAME <br /> Tait Environmental Services 916 439-2407 <br /> HOME or MAILING ADDRESS <br /> 11280 Trade Center Drive (916 1 858-1011 <br /> CITY Rancho Cordova STATE Ca Zip 95742 <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 /> 1 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,ST TE a FEDE L laws. <br /> APPLICANT'S SIGNATURE: DATE: 5/5/2015 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT Agent For Owner <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 <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br /> information t0 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: <br /> COMMENTS: ED <br /> MAV 0 61015 <br /> SAEJOAQUIIV t 0 <br /> NEgLTM pE AI?7'Al 7y <br /> ACCEPTED BY: EMPLOYEE#: DATE: .' <br /> ASSIGNED TO: f^ EMPLOYEE#: DATE: !Z�2–1,9 <br /> Date Service Completed (if al ady completed): SERVICE CODE: )9c� PIE: .2?;U <br /> Fee Amount: �G'O Amount Paid — Payment Date s�b/I<- <br /> Payment <br /> /<- <br /> Payment Type Invoice# Check# !9-11 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />