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SAN JOAQUItrt;f)UNTYENVI^,.ONM+,NTALHEALTH)m,�.RTMENT <br /> SERVICE REQUEST <br /> Type of Business or Properly FACILITY ID# SERVICE REQUEST# <br /> 52 ob ZION, <br /> OWNER I OPERATOR CHECK N BILLING ADDRESS© <br /> FACILITY NAME <br /> SITEADDRESS 5801 Foppiano Lane Stockton 95212 <br /> Street Number Dir.c' t eet Name CnY ZipCode <br /> HOME or MAILING ADDRESS (If Different from Site Address) 11§75 Mayers t Name Road <br /> treat Number trae <br /> CITY STATE Zip <br /> Acarnpo California <br /> PHONE#1 �T APN# LAND USE APPLICATION# <br /> (209) 365-1758 085-390-14 PA-0400392 <br /> PHONE#2 Ezr. JDOS Di5'e'�c r LOCATION CODE <br /> ( I <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR CHECK If BILLING ADDRESS <br /> Nancy ROSUIPk <br /> BUSINESS NAME PHONE# En. <br /> Nail () Andernnnnnil Associates Inc (209)367-3ZOI <br /> HOME Or MAILING ADDRESS FAx# <br /> 902 Industria W t ) -42 <br /> CITU STATE Zip <br /> CA 95240 <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 /> 1 also certify that 1 have prepared this application and that the or perfor ed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE and FED AAL I w . <br /> X APPLICANT'S SIG DATE: ( 2 7 <br /> I \ <br /> PROPERTY/BUSINESS OWNER OPERATOR MA R ❑ HER AUTHORIZED AGENT❑ <br /> ffAPPctCANT is not the BILLING PAR77'..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 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. ,�p <br /> TYPE OF SERVICE REQUESTED:;0if-SUltabillty Study Review Ny� � L� �i N� S I t.L- Y NT <br /> COMMENTS: /O/2O/CJS /''&y Ca <br /> 7 2005 <br /> /2o d"-V) SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> /�. HEALTH DEPARTMENT <br /> APPROVED BY: � EMPLOYEE#: ©DII DATE: <br /> ASSIGNED TO: <br /> EMPLOYEE �,Z 7-� <br /> Date Service Com leted (if already completed): SERVICE Cit <br /> Fee Amount: l� Amount Paid 9 Lk(>!S.0 0 Payment Date <br /> Payment Type - Invoice# Check# <br /> EHD 48-01-025 SERVICE REQUEST FORM <br /> REVISED 6-5-02 <br />