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k <br /> SAN JOAQUIN COUNTY ENVIRONM <br /> ,,ENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR MENCARINI CHECK if BILLING ADDRESS® <br /> FACILITY NAME MENCARINI PROPERTY <br /> SITE ADDRESS 1150 W TURNER ROAD LODI <br /> Street Number Direction Street Name Ci ZI Code <br /> HOME Or MAILING ADDRESS (if Different from Site Address) ' <br /> Street Number Street Name <br /> CITY STATE ZIP ' <br /> Ex-r. APN# LAND USE APPLICATION# <br /> PHDNE#1 029-020-02 PA-07-082 <br /> I <br /> PHONE#2 <br /> Exr• BOS DISTRICT LOCATION CODE <br /> CONTRACTOR 1 SERVICE REQUESTOR <br />( REQl1E5T0 A CHECK if BILLING ADDRESS❑ <br /> PHONE# ExT. <br /> BUSINESS NAM ql`—4LO L2, <br /> HOME or MAILING ADDRE vv AJ� F�� ) <br /> CITY e STATE .A ZIP Q� <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 I have prepared this applic •o d th he ork to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STA E FED la s <br /> APPLICANT'S SIGNATURE: DATE: r <br /> PROPERTY/14USINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> If APPLICANT is not the BILLING PAR 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: <br /> COMMENTS: / / REC�!FI � T <br /> V D <br /> AUG 1 ,g 2008 <br /> SAN <br /> IV �- <br /> E —co <br /> APPROVED B EMPLOYEE#: A TI{p i, T <br /> ASSIGNED TO: EMPLOYEE#: 01 <br /> D110 <br /> ATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P!E' v <br /> Fee Amount: Amount Paid 5 'Z s CSU Payment Date <br /> Payment Type !n-; <br /> Invoice# Check# l 1 1 Received y: �� <br /> SERVICE REQUEST FORM <br /> EHD 48-01-025 <br /> REVISED 6-5-02 <br /> R s <br />