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SANJOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> SKoo 4 gUz(D <br /> OWNER/OPERATOR Verne Schultz CNECKNBILLING ADDRESS❑ <br /> FAciuTY NAME <br /> SITE ADDRESS 31450 East Lone Tree Road Oakdale 95361 <br /> Strati Number tre t Name CHN Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) 31146 East Lone Tree Road <br /> SVeet Number SVet Name <br /> CITY Oakdale STA CA zip 95361 <br /> PHONE 81 E><*. APN# LAND USE APPLICATION# <br /> 1 209) 847-0516 229-150-06 <br /> ( LOCATION ODE PHONE#2BO$DISTRICT a <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> Verne Schultz CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# En' <br /> 209 1 847-0516 <br /> HOME Or MAILING ADDRESS FAS# <br /> 31146 East Lone Tree Road (209) 848-1301 <br /> CITY Oakdale STATE CA ZIP 95361 <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 b erfa a ill ne in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,S A'�and FEDERAL 18 <br /> c _" -x-,' 1 _ _ J <br /> APPLICANT'S SIGNATURE: / DATE: <br /> PROPERTY/BUSINESS OWNER Lid OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> IjAPPLICANT is not the BILLING PAR rr 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 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: L <br /> COMMENTS � PEC I V <br /> RECEIVED <br /> (01 /ot, J�GV ( rfZ M e� <br /> AUG 3 0 2006 <br /> SAN JOAQUIN COUNTY <br /> APPROVED BY: v1H N1 'RTM - Pt=' DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: 1S PIE: <br /> Fee Amount: S Amount Paid 8 90 Payment Date 0 1.3 pt0(� <br /> Payment Type Invoice# Check# paReceived By: 2� <br /> EHD 48-01-025 SERVICE REQUEST FORM <br /> REVISED 6-5-02 <br />