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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH I PARTMENT' ` <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR Pablo Vente c/o Al Sarieh <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS 17 N. Hinkley Ave. Stockton 95205 <br /> SOYA Number onStreet Name ciw Zlo C.d. <br /> HOME or MAILING ADDRESS (N Different from Ske Address) 1222 Monaco Ct, Ste. 25 <br /> Street Number Street Name <br /> CITY Stockton STATE CA ZIP 95207 <br /> PHONE#1 Ext. APN# LAND USE APPLICATION# <br /> ( 209)546-1827 157-210-22 <br /> PHONE#2 Ext. BOS DISTRICT 2 LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR Tina Cheney <br /> CHECK if BILLING ADDRESS <br /> BUSINESS NAMEPHONE 11 Er'' <br /> Neil O. Anderson & Associates Inc. 209 367-3701 <br /> HOME Or MAILING ADDRESS FAX# <br /> 902 Industrial Way (209 )369-4228 <br /> CITY Lodi STATE CA ZIP 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 1 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: ( V01�Uo DATEp:� <br /> PROPERTY/BUSINESS OWNER 13 OPERATOR/MANA ER OTHER AUTHORIZED AGENT AGI ie G <br /> lfAPPLICANT is not the BILLING PARTY fl of 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 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: T <br /> COMMENTS: " <br /> SEP 8 zoos <br /> S�t viFiONtMENTAL <br /> APPROVED BY: EMPLOYEE#: SH "422/ <br /> ASSIGNEDTO: EMPLOYEE#:Date Service Completed (if already completed): SERVICE CODE Fee Amount: IAmount Paid � qv, O Payment DatePayment Type j Invoice# Check# <br /> EHD 48-01-025 SERVICE REQUEST FORM <br /> REVISED 6-5-02 <br />